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° <br />INSTRUCTIONS FOR COMPLETING FORM ,B" ° <br />GENERAL INSTRUCTIONS: <br />I One FORM ^B^ hall be completed for, each tonk for, all NEN PERMITS, PERMIT CHANGES' REMOVALS and/or any <br />other TANK INFORMATION CHANGE <br />_ 2 <br />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, Jcopies.-^ <br />TOP OF FORM: 'MARK ONLY ONE ITEM" - ' <br />I. Hark an (X) in the boxnext to the item that best describes the reason the form is being completed, <br />2, Indicate the-DBAOr-Fa-ciT1ty name where the tank is installed, <br />' ' '- <br />I. TANK UESCR1P|l0N -COMPLETE ALL ITEMS ~ 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 ank <br />(ex � A870788).��_ <br />Q� Indicate the name of the company tha� manufactured fhe 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 10.008 etc.) <br />Il. TANK CONTENTS <br />A, <br />l, IF <br />MOTOR VEHICLE FUEL. Check box l and Complete items 8 <br />& C� }{ <br />2, If <br />riot MOTOR VEHICLE FUEL, check the appropriate box in <br />section A and complete. items B & D <br />B. <br />Check <br />the appropriate box, , �� <br />C, <br />Check <br />the type of MOTOR VEHICLE FUEL (1f bo�l is checked <br />in A). <br />D. <br />Print <br />the chemical name of the hazardous substance stored <br />in the tank and the C.A.3.#, (Chemical <br />Abstract Service number), if box l is NOT checked in A. <br />III. <br />TANK <br />CONSTRUCTION ~ NARK ONE }TEM ONLY IN BOX A. <br />B. C & D <br />l <br />Check <br />only one item 'in TYPE OF 5Y5TEM, TANK MATERIAL, INTERIOR <br />LINDMG and CORROSION PROTECTION. <br />2� <br />If 0THER, <br />print, in the sp�ce provided. ~ <br />I^'Cirde A if abnve round Circle U if underground' and ircle both if applicable. <br />2 IfUNKNOWN c1rcle� 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 />_ <br />`J <br />V. TANK LEAK DETECTION = <br />� <br />I, lnd1cote the !LEAK DFT ECTION system(s) used to comply with the monitoring requirements for the tank. <br />VT. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />IESTIMATED DATE LAST USED ' MONTH/YEAR (January, 1.988 or 01/88) <br />2 EST }MATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), <br />3. WAS TANK FILLED WITH INERT NATER141?` Check 'Yes' Or, 'NO' <br />� <br />APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br />INSTRUCTION FOR THE LOCA[ AGENCIES <br />The state und&qr0und storage tank identification number i's COmpOSGd Of the two digit, county number, the three <br />digit jurisdiction -number, the six digit facility number and the Six digit tank number, The rounty and <br />jurisdiction numbers are predetermined arid can be obtained by calling the State Board (916) 227-4303. The <br />fac1lity number must be the same as shown in form ''A^ The tank number may be assigned by the local agency, <br />however, thisnvmber must be numerical and cannot contain an alphabet. If the local agency prefers the State <br />Board to assign the tank number, please leave it blank. ' - - --- <br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br />INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY~ INFORMATION BOX <br />AND FOR FORWARDING ONE FORM ^A~ AND ASSOCIATED FORM ^B~(s) TO THE FOLLOWING ADDRESS. <br />~ <br />