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INSTRUCITONS FOR COMPLIT'17NG FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One NORM "B"shall be completed for each tank for all NEW PERMITS,PI?RMCT CILANGES, REMOVALS and/or any <br /> - other TANK INFORMK110N CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE HEW <br /> 1. Mark an(X)in the box next to the item thrit best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name wheree the tank is installed. <br /> L TANK DESCRIPTION-COMPLETE ALL 1T AS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank (ex.AB70789). <br /> B. Indicate the name of the company that n98nrfii-.tured the tank(c-4'-A.CME TANK MFG.). <br /> C. Indicate the year the tank was installed (tx. 19fi7). <br /> D. Indicate the tank capacity in gallons(ex. 2.5,1YT;)r 10,000 etc.). <br /> H. TANK CONTENTS <br /> A. 1.If MOTOR VEHICLE FUEL,,check box 1 and complete items B& C. <br /> 2.If not MOTOR VEHICLE FL`EL,check the appropriate box in section A and complete items B&I). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&I) <br /> 1.. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INI'ERIOR LINING and CORROSION PROTECI70N. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DSII;.CI10N <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CI.X)SED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONIll/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTI71 INERT MATERIAL? Check <br /> APPLICANT MUST SIGN AND DATE?11-1E FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction <br /> number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in form"A". The <br /> tank number may be assigned by the local agency;however,this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,pleasc leave it blank. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY 1I1AT INSPECINTI111 FACILITY TO VERIFY THE <br /> ACCURACY OF T1IE INFORMATION. TILE LOCAL,AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIIE <br /> •LOCAL.AGENCY USE ONLY'INFORMAITON BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM-13-(s)TO THE FOLLOWING ADDRESS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S-WX.EPS. - <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90')x3 <br />