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MW4 3;"v WW S 'W�7- INSURUCHONS FOR COMPLV1*k)RM *11' CHWE RAI, INSTRUCtIONS. 1. One FORM "B" shall be completed ft)r each tank for all NEW PERMITS, PERMIT CHANGE -S, RFMOVAI-S and/or any other TANK IN17ORMSIION CIIANGE. 2. 'Ibis form should be completed by either the PFRmrr APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM. "MARK ONLY ow num*. 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA ors Facility name where the tank is installed. 1. TANK DESCRIVITON - COMPLUIT, ALL r1'EMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank 11.) # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG.), C. Indicate the year the tank was installed (ex. 1.987). 1). Indicate the tank capacity in gallons (ex. 25,000 or 1.0,000 etc.). IL TANK (X)NIENI'S A. 1. If MOTOR VEHICLE FUI: L, check box 1. and complete items B & C. 2. If not MOTOR V17111CLI", ' FUFT, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C'. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box I is NOT checked in A. 111. TANK CONt;FRUC'11ON - MARK ONii rmw ONLY IN BOX A, 11, C & D 1. Check only one item in 'TYPE: OF SYSTEM, TANK MATERIAL, IV-113RIOR LINING and CORROSION PROTEC'nON. 2. If O'nIER, print in the space provided. IV. PIPING INFORMA'ITON 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if O'11JER, print in space provided. 3. Indicate the LEAK DF-ITcrioN system(s) used to comply with the monitoring requirement for the piping. V. TANK 11Q DUlWI70N 1. Indicate the LEAK system(s) used to comply with the monitoring requirements for the tank. V1. INFORMATION ON TANK PERMANEN11,Y CLOSED IN PLACE 1. RS-11MA11-0 DAnF. LAST' USED - MONI'll/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTrI'Y of IIA7ARI)OUS SUBSTANCE remaining in the tank (in Gallons). 41 3. WAS TANK FILLED WITH INT,',Kl' MATERIAL? Check 'Yes' or 'NO'. APPLICAN'r musr SIGN AND DA111,111F FORM AS INDICW11zD. INSTRUCnON FOR71TE 1,0(:AL AGENCIP-9 The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. "The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank-, r1'IS 17 -JE RE -SPONS113111rY OF'n][H LOCAL AGENCY THAT INSPI". N111F. FAC ILFIN1`0 VERIFY 11TIE ACCURACY OV7II-11?INI?ORMA'IION. "Ili LOCALAGEN(Y IS RESPONSIBLE FOR'nIECOMPTHITON OF111E 'LOCAL AGENCY USE ONLY* INFORMAMON BOX AND FOR FORWARDING ONE FORM "A* AND ASSOCIATED FORM -Ir(s) TO ITIE F0111)WING ADDRESS. 917NIT3 OF CALIFORNIA STNIT! WR I'ER RESOURCUS CON-I'ROI, BOARD C/o S.W.I?np.S. DATA PROCESSING C11NIT,-R P.O. BOX 527 PARAMOUNT, CA 90-M