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INSI'RUCTIONS FOR COMPLVIING FORM"B" <br /> GENERAL INSI"RU( i kONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMnN, PERMIT CIIANGES„ R.EMOVAIS and/or any <br /> other TANK INFORMA11ON CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the I..00AL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print dearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE rI1?M" <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 /> L TANK DESCRIPTION-C OMPLU E ALL,ITEMS-W UNKNOWN-SO SPE:CWY <br /> A. Indicate owners tank ID#-If there is a.tank number that is used by the owner to identify the tans: (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 /> II. TANK CONIIWI*S <br /> A. 1. If MOTOR VEHICLE 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 /> B. 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 1 is NOT checked in A. <br /> EEL TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MA'T'ERIAL,INTERIOR LINING and CORROSION PRO'I'EiCI'ION. <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 OTHER,print in space provided. <br /> 3. Indicate the LEAK D=CON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLTIF.CTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CI.ASII)IN PLACE; <br /> 1. ESTIMATED DATE LAST USED-MONIT-I/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITII INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 1111;FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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 sac 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 /> rT IS THE RESPONSIBILITY OF T.HE LOCAL AGENCY TIINI'INSPE M TIIE FACILITY TO VERIFY THE? <br /> ACCURACY OF 111E INFORMATION. THE LOCAL AGENCY IS RFSTONSIBLE FOR TILE COMPLETION OF T1IE <br /> 'LOCAL.AGENCY USE ONLY'INFORMN11ON BOX AND FOR FORWARDING ONE FORM"A'AND ASSOCIATED <br /> FORM'B'(s)TO THE FOLLOWING ADDRES!& <br /> STATE.OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL HOARD <br /> C/O&W.EE P.5. <br /> DATA PROCESSING CI WTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />