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INSTRUCTIONS FOR COMPLETING l 'B" <br /> GENE3RAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMTI.':i,PERM[r CHANGES, RF.MOVAI.S and/or any <br /> other'TANK INFORMt1110N CIIANGE. <br /> 2. This form should be completed by either the PERMrr APPLICANT or the IX)CAL AGENCY UNDERGROUND 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 FORM:*MARK ONLY ONE TI'EM" <br /> L 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 DFSCRIP'I1ON-COMPI.UFF,ALL TITWS-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.A1370789). <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 CONTFNIS <br /> A. 1. If MOTOR VEHICLE FUl"L,check box 1 and complete items B& C. <br /> 2.If not MOTOR VIFIICLE 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 CONST7iUCnON-MARK ONE 1`11W ONLY IN BOX A,B,C&D <br /> 1. Cheek only one item in'I`YPE OF SYSTEM,TANK MATERIAL,, INFERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INF(3RMA7ION <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 DETF',CTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVI7 CI1ON <br /> 1. Indicate the LEAK DI 1.1?(,711OiN systems) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANFNI7M C'.1,O%T0 IN PLACE <br /> 1. ESTIMATED DATE I..AST USED -MONTFI/YFAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN FFY of IIAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT`NINFERIAL?Check'Yes'or'NO'. <br /> APPI1CAN1'MUST SIGN AND DA7111 THE FORM AS INDIC:liIED. <br /> INSTRUC11ON FOR 11IE 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. 'Me 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 11111 RTSPONSIBHXI Y OF THIS LCXAL AGINC`Y TF1A.0 INSPEC N 11II?FAC:ILTrY TO VERIFY TILT? <br /> t <br /> ACLU ('Y OF TIIE INFORMATION. '171113IXX:AL AGENCY IS RESPONSIBLE FOR 7111E COMPLETION OF 111E <br /> 'IXX'AI..AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM'B'(s)1.0111E FOIdAWING ADDRESS. <br /> SrA'IT?OF CALIFORNIA <br /> S NI'E WA17?R RESOURCES CONIROL BOARD <br /> C/O S.W.E.F..P.S. <br /> DATA PROCESSING CFNI7?R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />