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INSTRUCTIONS FOR COMPLETING*M*B" • <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM'B"shall be completed for each tank for all NEW PERMr17S,PERMIT CIIANGM REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PFRmrI'APPL[CANJ`or the IA)CAL AGENCY UNDERGROIUNDTANK <br /> I NST ECI`0R <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�TORW- *MARK ONLY ONE nEm" <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 /> I. TANK DESCRIPTION-COMP1ffq`E ALL TIVMS-It'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. 25,000 or 10,000 etc.). <br /> H. TANK CONTFNI'S <br /> A. 1. If MOTOR VEHICLE IUI.L,check box I 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 I is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE r1TN ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE.OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECIION. <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 DE I'ECi)ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I,EAK DETECTION <br /> 1. Indicate the LEAK DFI'ECI1ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PER MANFNIIY CUDSM)IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSIANCE remaining in the tank (in Gallons). <br /> 1t WAS TANK FILLED WIT11 INERT MATERIAL? Check'Yes'or'NO'. <br /> APPI1CANT MUST SIGN AND DXMTTIF,FORM AS INDICA113D. <br /> INSTRUCTION FOR THE LocAll,AGuNcrus <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 /> 117'IS THE RESPONSIBRXI'Y OF 1TIE LOCAL AGENCY 111AIANSPECIN THE FAC 111ff 170 VERIFY THE <br /> ACCURACY OF ITIF INFORMATION. 11-113 LOCAL AGENCY IS RESPONSIBLE FORIIIE COMPI=ON OFIIJE <br /> "LOCAL.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM-B-(s)TO IIIE FOLLOWING ADDRESS. <br /> SrA:M7 OF CALIFORNIA <br /> STATE WATER RESOURCIN CONIMOL BOARD <br /> C/o S.W.E.E.Ps, <br /> DATA PROCESSING CENTER <br /> P.O.BOX S27 <br /> PARAMOUNT,CA 90723 <br />