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4 <br /> 40 <br /> INS71RUCIIONS FOR COMPI FLING FORM"B" <br /> GENERAL INSI RIJ C 0"ONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMrtS,PERMIT CIIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI.ICANT 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 rmw <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 D13SC:REMON-COMPLINT,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.75,000 or 10,000 etc.). <br /> U. TANK CONTENIS <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&I). <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 CONS-IRUCTION-MARK ONE rI`EM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in 1 YPE 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 DETBCIION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEIF.Ct10N <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENII-Y CLOSED IN PIACI? <br /> 1. ESTIMATED DATE IASI'USED-MONIII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTI11 INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 1111;FORM AS INDICATED. <br /> INS1rRUC110N FOR TIIE 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 /> IT IS TIII3 RESPONSIBILITY OF 71111 LOCAL AGENCY THAT INSPECTS THE FACHMY TO VERIFY THE <br /> ACCURACY OF TILE INFORMA110N. 111E LOCAL,AGENCY IS RESPONSIBLE FOR THF C.OMPLL ION OF TIT: <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A-AND ASSOCIATED <br /> FORM-B-(s)TO T1IE FOLLOWING ADDRESS, <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.I?E.P.S. <br /> DATA PROC'ENSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90713 <br />