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INSTRUCITONS FOR COMPTJM. NG A"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM'B"shall be completed for each tank for all NEW PFRMrM PERMrICHANGFA RFMOVAI-S and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2. This form should be completed by either the PFRMIT APPLICANT or the LOCAL AGENCY UNDERGR01UNDTANK <br /> INSPEC-170R. <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 nwe <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 DESCR1Y11ON-COMPIJEW,ALL IT'E'MS-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. 25,000 or 10,000 etc.). <br /> Ill. TANK CONTFMI'S <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VE4'HICLE 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 CONS71'RUCTION-MARK ONE 1`11W ONLY IN BOX A,B,C&D <br /> 1. Check only one item in`TYPE OFSYSTEM,TANK NINFERIAL, IN71-ERIOR LINING and CORROSION PROTEC7110N. <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'17EC`FION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> . 1. Indicate the LEAK DET.'E(-IION system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE, <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wri-H INERT'MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 111E FORM AS INDICATED. <br /> INSTRUC'11ON FOR TIIE3 LOCAL AGE14CW—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(9"16)739-2421. r Ille 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 /> ITIS THE RF—SPONSEBfLrI'Y OF THE LOCAL AGENCY THAT INSPE(-,11,'771E FACILITY'10 VERIFY 11IF <br /> ACCURACY OF TME INFO TION. '111E LOCAL AGENCY IS RESPONSIBLE FOR THE3 COMPLLMON OF 1771E, <br /> "LO AL AGENCY USE ONLY,INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM-W(s)'10-nIE FOIJX)WING ADDRESS. <br /> STATE OF CALIFORNIA <br /> - <br /> STATE WATER RESOURCES CONI'ROL BOARD <br /> C/o S.W.E.E.PS. <br /> DATA PROCESSING CFNIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90-M <br />