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INSTRUCTIONS FOR COMPI.d?I'ING A'B" • <br /> GENE7RAI,INSIRUC'ITONS: <br /> 1.- One FORM"B"shall be completed for each tank for all NEW PERMI7.S,PERWr CFIANGFS,:RE.MOVAIS and/or any <br /> other TANK INFORMN11ON CIIANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the I I..AGI?IVCY UNDI3RGROUND'TANK <br /> INSP R <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 num?, <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-CY)MPI.131713.ALI.TIT4MS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11.) # -If there is a tank number that is used by the owner to identify the tank(ex.A137089). <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.25,040 or 10,000 ctc.). <br /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE FUEL,check box I and complete items B& C. <br /> 2. If not 'MOTOR VIAIICLE 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 VEIIIC LE 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 CONS.IRUCTION-MARK ONE 1`113M ONLY IN BOX A,K C&D <br /> I. Check only one item in TYPE OF SYSTEM,`TANK MATERIAL,, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> I. Circle A.if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIFR,print in space provided. <br /> 3. Indicate the LEAK DFTIs(7I'[ON sy-item(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LE AX DTq'FCIION <br /> 1. Indicate the LFAK DETE,CHON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PFRMANFNI7:Y CT.O.SFD IN PLACE <br /> 1. ESTIMATED DAVE I..AST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ISTIMATED QL'ANTPI.Y of IIAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check'Yes' or'NO'. <br /> APPtdC'AN`r MUST SIGN AND Dt1I1?*1711F FORM AS ICAI'E1). <br /> I.NSTRU(:ITON FOR 111E I )CAL 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)739-2421. 'Che 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 /> TI'IS THE RESPONSIBUXI'Y OF THE LOCAL AGENCY THAI'INSPE.+C'T511IL FACILITY TO VERIF�TIIE <br /> ACCURAC7Y OF TIIF INFORMATION. TIIL IAXAL AGENCY IS RESPONSIBLE FOR TIII3 COMPLETION OF ut <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM"B"(s)TO 11111 FOLLOWING ADDRESS. <br /> STA:113 OF CALIFORNIA <br /> SPATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.F_P.S. <br /> DNrA PROC ICING CFN113R <br /> P.O.BOX 527 <br /> PARAMOUNT,CAA 40223 <br /> • <br />