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INSTRUCTIONS FOR COMPLETING I "B" <br /> GENERAL INS'IRUCIION& <br /> 1. One FORM'B"shall be completed for each tank for all NEW PERMrIS,PERM[r CHANGES, REMOVA.I.S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL.AGENCY UNDERC ROUND'TANK <br /> INSPECTOR <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 FC)RM:"MARK ONLY ONE r1Em, <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 DFSC:RIVIION-CY)MPI,E'rE ALL rrEMS-H-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 CONTENTS <br /> A. 1. If MOTOR VEHICLE FUI,L,check box I and complete items B & C. <br /> 2.If not MOTOR VEHICLE FUH'L,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 F 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 CONSTRUCTION-MARK ONE 1`113M ONLY IN BOX A,11,C&D <br /> 1. 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 /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKINOWN,circle; or if O'I'LIER print in space provided. <br /> 3. Indicate the LEAK DETI;(`I'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE.I'EC11ON <br /> 1. Indicate the L LAK DEI'ECIION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON'TANK PFRMANFN11 Y CZOSFD IN PLACE <br /> 1. FSTIMATFD DATE I..AST USED-MON11/YI3AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN1TITY of IIAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INER717,MA'TFRIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA17THE FORM AS INDICNI'EI). <br /> INSTRUCTION FOR 111E LOCAL.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. '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 /> rT IS THE RESPONSIBU I'Y OF THE LOCAL AGENCY THAT INSPECTS'I1IE FAC lUrY'I )VERIFY 171113 <br /> ACCURACY OF UW INFORMATION. 'I1IE?I..(X:AL AGENCY IS RESPONSIBLE FOR 711IE COMPLUTION OF 111E <br /> "LOCAL,AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A'AND ASSOCIATED <br /> FORM"B"(s)`TO THE FOI.I.OWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> ST'NI'E WtlI13R RESOURCES CONTROL BOARD <br /> C/O S.W.E.ELP.S. <br /> DATA PROCESSING C:ENIER <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 90723 <br />