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mgrRucnoms FOR COMP1111ING FORM*B* <br /> GENERAL INSI'RU C. ONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMrn,PERMI7r CHANGES, REMOVALS and/or any <br /> other TANK INIX)RMATION CHANGE. <br /> 2. 17his form should be completed by either the PERMrF APPLICANT'or the LO(AL AGENCY UNDER6ROUNDTANK <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 /> '170P OF FORM: "MARK ONLY ONE rIT2W <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 /> 1. TANK D0SCRIP`17ON-COMPLETE ALL r11WS-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 CONTENIN <br /> A. 1. If MOTOR VEHIC1.11 FUEL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEI-11C1.11 FUEL,check the appropriate box in section A and complete items B& D. <br /> R Check the appropriate box. <br /> C. Check the type of MOTOR VE-MICLE 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 /> 111. TANK CfJNSTRUC17ION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'l-fPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION PRo'nIx7nON. <br /> 2. If OTIIEF, 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 OT1IFR,print in space provided. <br /> 3. Indicate the LEAK DEIECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LFAK DLrr.P(7.[ION <br /> 1. Indicate the LFAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON TANK PERMANI.WILY CI.,OSED IN PLACE <br /> 1. ESTIMAT1.4.13 DATE IAST USED -MONT11/YMR(January, 1988 or 01/88). <br /> 1 F--STIMATED QUANrl-rl'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATE-RIAL? Check 'Yes'or'NO'. <br /> APPLicAw musr SIGN AND DATE?31IF FORM AS INDICATED. <br /> INS-IRUCIION FOR =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 /> H'ISTHE RESPONSIBHrI'Y OF 11111 WCAL AGENCY 111ATINSPECIS TIJE FACILrITTO VERIFY ITH! <br /> ACCURACY OFTIW,INFORMATION. 11111 LOCAL AGENCY IS RESPONSIBLE FOR ITIE,COMPIH110N OF ITIE <br /> "LOCAL AGENCY USI!ONLY"INPORMNIION BOX ANT) FOR FORWARDING ONE FORM *A"AND ASSOC[NIED <br /> FORM 'B'(s)TO-11111 FOI.1A)Wt.N(.-,ADDRESS. <br /> STNI11 OF CALIFORNIA <br /> STNITT,WATER RESOURCES CONTROL BOARD <br /> C/o&Wn E.P.S. <br /> DATA PROCESSING(3:1141E.R. <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />