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--7---- <br /> INSTRUCTIONS FOR COMPLEUING FORM*B" <br /> GENERAL INSTRU(7fTONS: <br /> 1, One FORM"B"shall be completed for each tank for all NEW PERM171N,PERMIT CHANGES, REMOVAUS and/or any <br /> other'TANK INFORMATION CHANGE. <br /> 2, 'Phis form should be completed by either the PERmrr APPLICANI*or the LOCAL AGENCY UNDERGROUND TANK <br /> I NS P E C.TO R. <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 nim <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 1 Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK DESCRIPTION-COMPLE17i ALI.1r1`EMS-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.ACMETANK 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 /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEHIC1.14 FUEL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE' FUEL,check the appropriate box in section A and complete items B& D. <br /> 13, Check the appropriate box. <br /> C. Check the type of MOTOR VEHICI.Ai.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 MW.. ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PRO711=10N. <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 0111EIZ,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 Df!rF(-IION <br /> 1, Indicate the LEAK DE-II-X71ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENI'LY CIA)SED IN PLACE <br /> 1, ESTIMA'I'E,D DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of I IAVARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT'MA'T'ERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DW1`E1 71111 FORM As INDICTED. <br /> INSTRUCTION FOR 111H 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,please leave it blank. <br /> ri,is li'liti RESP(.)NSIBHXI.'Y OF THE LOCAL AGENCY THAI'INSPIX717S 71111 FACILITIf TO VER117f'ITIE <br /> ACCURACY OF'11IE INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBIE FOR7111E.COMTI1;'I1ON OF 7171E <br /> *LOCAL AGENCY Usti ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIA*IF1) <br /> FORM-Ir(s)TO 1.1111 FOIAOWING ADDRESS. <br /> SrAIE OF CALIFORNIA <br /> STNI11 WNIT.R RESOURCES CONTROL BOARD <br /> C/O S.W.Ll E.P.S. <br /> DATA PROC33SSINCY CENIVIR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90773 <br />