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msauucnoms FOR COMP11ANG FORM -B- 0 <br />GENERAL INI�I'RUCTIONS: <br />1. One FORM "B"sball be completed for each tank for all NEW PFRMrIS, PFRmrr CHANGES, REMOVALS arae /or, any <br />other 'TANK INFORMffl.'ION CHANGE <br />2. This form should be completed by either the PERMIT APPIACAN.I'or the LO(Al, AGENCY UNDFRGROUNDTANK <br />INSPEC1,70R. <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 now <br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br />2. Indicate the DBA or Facility name where the tank is installed. <br />I. TANK DESCRIVITON - C!OMPLIU`Ei ALL 1`11BMS - 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 manufactured the tank (ex. ACME; TANK MFG.). <br />C. Indicate the year the tank was installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />11. TANK CON117NFS <br />A. 1. If MOTOR VEHIC1.111 FUEL, check box I and complete items B & C <br />2. If. not MOTOR VEITICLI. FUEL, check the appropriate box in section A and complete item.,,- B & D. <br />13, 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 I is NOT checked in A. <br />111. TANK CONSTRUCTION - MARK ONE MIM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INIM RIO R LINING and CORROSION PROITCHON. <br />2. If OILIER, print in the space provided. <br />I tym a) a 111! Eta Q 101 1*41 "1 101 z <br />L 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 DP-ri-,criON system(s) used to comply with the monitoring requirement for the piping, <br />V. TANK LFAK DV- rE(711ON <br />1. Indicate the LEAK DLII ,,CI'ION systern(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMNIION ON "TANK PERMANINILY C1,OSED IN PLACE <br />1. EsTimArI:,D DATE f.AsT USED - MONT[I/Yl."!AR (January, 1,988 or 01/88). <br />2. ESTIMATED QUAN`I'rrY of HAZARDOUS SUBS I'ANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MA11..RIAL? Check 'Yes' or 'NO'. <br />APPLICANI' MUST SIGN AND DA711z, '11111 FORM AS INDI(WI'L71). <br />INSTRUCTION FOR 7191? LOCAL AGENC[IIS <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 Sta+e Board to assign the tank number, please leave it blank. <br />II' IS 111E RESPONSFBHrl'Y OF`111E IA)CAL AGENCY 171INFINSPECTS 11111 FACII1I*Y'I`O VERIFY'ITIE <br />ACCURACY 017THE INFORMATION. 1711E LOCAL AGENCY IS RESPONSIBLE FOR THE CONIPIX.-IlON OF11IF <br />*LOCAL AGENCY USE ONLY" INFORMA11ON BOX AND FOR F()RWARDING ONE FORM "A" AND ASSOCINIF.D <br />FORM 'B'(s) TO 111F FOI.IOWING, ADDRESS. <br />STATE OF CALIFORNIA <br />STNIE WATER RESOURCES C'ONT'ROL BOAR13 <br />C/O S.W.111 E.P.S. <br />DATA PROCESSING 01NIER <br />P.O. IIOX 527 <br />PARAMOUNT, CA 9WM <br />