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1-------,- 'W- - ---7 <br /> IN91RUCIIONS FOR COMPI.H19PORM"B" <br /> GENERAL INSTRUCTIONS: <br /> t One FORM"B"shall be completed for each tank for all NEW PERMI71'S,PERMIT CIIANGES, REMOVAUS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERmrr 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 1711W <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 DF.SCRIP`1TON-COMPI.131717-1 ALL r1TWS-III 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. 75,000 or 10,000 etc.). <br /> If. TANK CONIENrS <br /> A. 1. If MOTOR VEHIC111"FUEL,check box I 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 /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHIC1.1i FUEL(if box 1. is checked in A). <br /> 1). Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number),if box I is NOT checked in A. <br /> IIL TANK comsmucnolsl-MARK ONE mim ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM;'TANK MATERIAL,INTERIOR LINING and CORROSION PRoT13CT10N. <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 O'ITIER,print in space provided. <br /> 3. Indicate the LEAK DFI'ECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK Dl3TrVAA1ON <br /> 1. Indicate the LEAK DI-71'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA'DON ON'TANK PERMANI.WI7.Y CIA)SED IN PLACE <br /> 1, ESTIMATI.,D DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAVARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wins INEWr MA'FFRIAL? Check'Yes'or'NO'. <br /> APPIJCAN`r MUST SIGN AND DA711,711113,FORM AS INDICATED. <br /> INSTRUC11ON FOR 11111 IOCAL AGENC'W-S <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+c Board to assign the tank number,please leave it blank. <br /> rI'IS`nIE RESPONSIBI1XI,'Y 01711111 IA)CA1.AGENCY THAT INSPEM IIIE FAcurl'y'lo vi3RI1-'Y'I1lE <br /> ACCURACY OF'IIIE INFORMATION. THE LOCAI.AGENCY IS RESPONSIBLE FOR,nIE coMPLE'I1ON OF 7111E <br /> *LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM 'A*AND ASSOCIATED <br /> FORM'B'(s)TO 11111,FOLWWING ADDRESS. <br /> STA717E OF CALIFORNIA <br /> 9rA'IU WAIT.R RESOURCIIS CONTI'ROL BOARD <br /> C/O&W.F-E-P.S. <br /> DATA PROCESSING(M-NrElk <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />