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TIN X? <br /> INSTRUCTIONS FOR COMPLETING FORM"B" <br /> GENERAL INtiI"R&JCiIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERWINPERMIT Utica.,, RI?MOVALS and/or any <br /> other TANK INFORMNIION CHANGE? <br /> 2. 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 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE rIE3M- <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-COMPLUM,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 tank (ex.A1370789). <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.19". <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> IL TANK CONIINES <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 /> III. TANK COW RUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CL.OSE0 IN PLACE <br /> I. ESTIMATED DATE LAST USED-MONI'H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIAL.ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE T1IE FORM AS INDICATED. <br /> INSTRUCTION FOR TIIE LOCAL.AGENC][ 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 State Board to assign the tank number,please leave it blank. <br /> rr IS TIM RESPONSIBIId]rY 01717111 LOCAL AGENCY THAT INSPECTS THE FACILITY TO VITRIFY TALI <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENC.'Y IS RESPONSIBLE FOR THE COMPLI311ON OF THE <br /> "LOCAI.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOCIATED <br /> FORM-B•(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE?WATER RESOURCES CONTROL BOARD <br /> C/O S.W.F_EP.S. <br /> DATA PROCUSSING CI:WrE?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90'M <br />