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INSTRUCTIONS FOR C'OMPII3IING I 'B' <br /> GENERAL INSTRUCTIONS: <br /> L One FORM"B"shall be completed for each tank for all NEW PERMIT S,PERMIT CIIANCsFS, REMOVALS and/or any <br /> otherTANK 11ON CHANGE. <br /> 2. Ibis form should be completed by either the PERMTr APPLICANT'or the tDCAL AGENCY UNDERGROUNDTANK <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 17ORM: "MARK ONLY ONE nEw <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 DESCRIPIION-COMPI.1TrE.ALL MWS-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.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MPG.). <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 CONTFNI'S <br /> A. 1. If MOTOR VEHICLE 17UEL,check box 1 and complete items B& C. <br /> 2.If not MOTOR VEHICLE FU 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 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 I11W ONLY IN BOX A,B,C&.D <br /> I. Check only one item in TYPE.OI'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 UNKNOWN,circle; or if OTIIER,print in space provided. <br /> 3. Indicate the LEAK DhT CION system(s) used to comply with the monitoring requirementfor the piping. <br /> V. TANK LEAK DE?T'ECI)ON <br /> 1. Indicate the 1.FAK DEI'ECI)ON system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PIiRMANENII.Y CI,C).SED IN PLACE <br /> 1. ESTIMATED DA11-1 I..AST USEI)-MONTH/Y PAR(January, 1988 or 01/98). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS'TANK IILLED WIl'll INER 'MATERIAL? Check'Yes'or;NO'. <br /> APPI1CAN`r MUST SIGN AND DXIT?111E FORM AS INDIC:AIM. <br /> INSTRUC:I)ON FOR 111E LOCAL A(;ENCW—% <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 /> I1'IS THE RESPONSIBHXI'Y OF THE LOCM,AGENCY THAT INSPECI:S ERE FAC:ILYTY TO VERIFY 11IE <br /> ACCURACY OF TIIE, INFORMATION. 171E LO(W_AGENCY IS RESPONSIBLE FOR 17113,COMP1HnON OF1111i <br /> 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM'B"(s)1Y)11113 FOII.OWING ADDRESS. <br /> AMIVI i OF CALIFORNIA <br /> SrNM WAI'ER RESOURCES CONI'ROL BOARD <br /> C/O S.W.E.E.P S. <br /> DATA PROCESSING CENII?R <br /> P.O. BOX 527 <br /> PARAMOUNT',CA 94M <br /> 0 <br />