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4 <br />INS'FRUCHONS Ik)R COMPI.VnNON lk)RM"Ir <br />GENERAL INK17RUC`ill NS: <br />1. One FORM 'B' shall be completed for each tank for all NEW PE Ii, PEWNIn'CHANGF-S, REMOVAIS and/or any <br />either TANK INTIORMS17ION CHANG11 ' <br />1 This form should be completed by either the irimmu APPI.ICANT or the LOC ALA(;F.N.CY UNDERGROUND TANK <br />INSTW, 1'OPL <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- OMARK ONLY ONE FIIN* <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 D13A or Facility name where the tank is installed. <br />L TANK DuscRimON - COMPLTqv, Au. rrums - W UNKNOWN - SO SPECIFY <br />A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the to (ex, A'1370789), <br />B. Indicate the name of the company that manufactured the tank (ex. ACMETANK MFG.). <br />C. Indicate the year the tank was installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex, 2.5,0 00 or 10,000 etc.). <br />11. TANK CONIUMIS <br />A� 1, If MO'I'OR VEHICLE FUEL, check box I and complete items B & C. <br />1 If not MOTOR IVEMICLE FUEL, check the appropriate box. in section A and complete items B & 1). <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE FUE�L (if box 1, is checked in A). <br />1). Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Serrice <br />number), if box I is Nar checked in A, <br />In. TANK CONSTRUMON - MARK ONE DUM ONLY IN TX) X A, B, C & 1) <br />L Check only one item mTYPE OF SYSITIM, TANK IMNI'ERIAL, INTERIOR LINING and CORROSION P1tOTEC110N, <br />2. If OTIJER, print in the space provided. <br />IV. PIPING IN11ORMA17ON <br />L Circle if above ground; circle U if underground; and circle both if applicable. <br />1 If UNKNOWN, circle, or if 01TIER, print in space provided. <br />3. Indicate the LEAK DETEC`I'TON system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK D1fI1XN10N <br />1. Indicate the LEAK DUIMCFIO'Nsystem(s) used to comply with the monitoring requirements for the tank, <br />1. F-,nmtvrm DAm, irks -r USED - MO,Kll]/YEAR (January, 1988 or 01/88). <br />2. ESTINIXIED QUANUM of HAZARDOUS SU115FANCE remaining in the tank (in Gallons). <br />3. WAS `PANIC FILLED WrIll IN1.14Wf NtNTERIAL? Check 'Yes'or'NO'. <br />APPUCAMr MUI;f SIGN AND )ATI? '11111 FORM AS INDICA113D. <br />1N,`;rRUC11ON FOR'n1E LOCAL AC3FN(31S <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. 'ne county and jurisdiction numbers are predetermined and <br />can be obtained by calling the State Board (91.6)739-2421, 'Fhe 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 />1"I'TSTHE RE.SPONSIBI1.UT OF°1"3111I.A)CAL AGINCIf ITIN17 INSPBM, 3111' 1 FAC 1111T TO VERIFY11113 <br />ACCURACY OF17113, INPORMA370N. 311E LOCAL AGENCY IS RESPONSIBLE POR'n1H (:X)MPLVPION OV "1"1113 <br />'IA)CAT, AGINCY USE ONLY� INMRMA`11ON BOX AND MR FORWARDING ONE FORM "A" AND ASSOCIA111,I) <br />MRM -B-(s)'1701111I F01-LOWIN1,A DDRF&S. <br />STNI711 OF CAI11X)RNIA <br />s -mm wAwk RiLsomms comrROL BOARD <br />C/o smlu�ps. <br />DXrA PROCTNSING CIIN`11�,R <br />P.O. 13()X 527 <br />PARAMOUNT, CA WM <br />