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INSIRUCnONS FOR COMPLIMNG K)RM *W <br />GENERAL 1N9rRUC11ONS. <br />1. One FORM "B" shall be completed for each tank for all NEW PI H'S, PERM171'CHANGES, REMOVAI-S and/or any <br />other TANK INFORMNIION CHANGE. <br />2. This form should be completed by either thq.PT-.Rmrr APPI..I(-,ANI'or the LOCAL AGENCY UNDERGROUND TANK <br />1NSPEC`FOR_ <br />3. Please type or print clearly all requested information. <br />4. Use a hard point writing instrument, you are making 3 copies. <br />1rOP*0F FORA 'MARK OMY OM! rIIN' 4 <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 DESCRWI70N - COMPLUITI, ALI. rIVAIS - 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 10,060 etq.). <br />H. TANK CONIMNIS <br />A. 1. If MOTOR VEHICLE FUEL, check box I and complete items B & C. <br />2, If not MO`I'OR VFfIICLE 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 I 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 Service <br />number), if. box I is NOT checked in A. <br />1IL TANK (X)NS`MU('I1ON - MARK ONE 171IN ONLY IN BOX A, B, C & D <br />L Check only one item in TYPE Of' SYS"IMM, TANK MATERIAL, INTERIOR 11NING and CORROSION PROTEC11.0N. <br />2. If OTHER, print in the space provided. <br />IV. PIPING INFORM)VIION <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 DVI'EIC7110N systeni(s) used to comply with the monitoring requirement for the piping. <br />V. TANK IEAK DVIWITON <br />1. Indicate the LEAK DETECTION system(s) used to comply vAlft the monitoring requirements for the tank. <br />VI. INFORMA11ON ON TANK PERMANEM11,Y CLOSED IN PIACE <br />1. 13,1�11MATED DATE I.A.51' USED - M0%rITI/YEAR (.January, 1988 or 01/88). <br />2. ESTIMATED QUANITFY of HAZARDOUS SUBSSFANCE remaining in the tank (in Gallons). <br />3. WAS TANkn, LLED W1111 INI:1RT MA-ITRIAL? Check 'Yes' or 'NO'. <br />APPLI(AN'r MUST' SIGN AND DATE171EFORM AS INDI(WIM. <br />INS`rRUC1'1ON FORTITE TDCAL 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)7.39-2421. 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 carmbitcontain an alphabet. If <br />the local agency prefers the State Board to assign the tank number, please leave it blank. <br />rr IS TnE wNPONSIBIL171Y OF ILLI? LOCAL AGIIN(*Y'niK.1'INSPI*!(,'['S'llif.1 FAr_1IrrY11O VERIFY 11HE <br />ACCURACY OF THE INFORMATION. 111E LOCAL AGENCY IS RESPONSIBLE FOR 111E COMPLE11ON OF 117IE <br />"LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIA1771) <br />FORM -1r(s) TO 11113 FOLLOWING ADDRESS. <br />SrNIF- OF CALIFORNIA <br />STATE WNIVR RE.SOUR(MS CONI'ROL BOARD 4 <br />DA`rA PROCESSING CER <br />P.O. BOX 527 <br />PARAMOUNI', CA 90723 <br />0 <br />0 <br />