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IN917RUCTIONS MR COMP113710 FORM'M <br /> GENERAL TM3TRUC`I1ONS- <br /> I, One FORM "B"shall be completed for each tank for all NEW PERMT17S,PERmn-CHAWMN, REMOVAI-S and/or anY <br /> other TANK INFORMATION CIIANGE <br /> 2. 'I'his form should be completed by either the PERMIT APPLICANT or the IOCAL AGENCY UNDERGROUND TAN k <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 /> 'FOP OF FORM:*MARK ONLY ONE 1TI,7A" <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-COMPLI-r1li ALL ITEMS-117 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, <br /> B. Indicate the name of the company that manufactured the tank(ex. ACMF',TANK MFO.). <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 /> 11. 'TANK CONIUNI'S <br /> A. 1. If MOTOR VEHICLE FUI."L,check box 1. and complete items B & C. <br /> 2. If not MOTOR VEHICLE 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 /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S4. (Chemical Abstract Scrvic<; <br /> number),if box 1 is NO'I'checked in A. <br /> 111. 'TANK CONSTRUCTION-MARK ONE rIM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MNIERIAL,INTE7RIOR LINING and CORROSION PROTEC7110N, <br /> 2. If OTI-TER,print in the space provided. <br /> TV. 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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DE'T'ECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LHAK DR`I`FC`110N <br /> 1. Indicate the LEAK DETE(,1riON system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON']'ANK PERMANENTIM CLOSED IN PLACE <br /> 1. E,,S.nN4A'1'1,;I) I)A'I'EIASTUSI^,D-moNnI/YEAR (January, 1988 or 01/88). <br /> 1 IMIMATI.4.)QUANTIFY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFITI INERT MATERIAL? Check 'Yes'or'N(Y. <br /> APPLICANT MUST SIGN AND DATE 111E FORM AS INDICA11-11). <br /> INSTRUCTION FORT1111 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-(91()739-242 1. 'Die 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 /> IT IS 111E RESPONSIBI1XI'Y OF THE LOCAL ACilIN(-'Y'lltNI'INSPECTS'IlIFI FACIL171"i'1170 VERIFY TIM <br /> ACCURACY 017111E IN1;?ORMXI10N. TIIE IA')CAL AGENCY IS RESPONSIBLE FOR'1111!COMPLETION OFTTIH <br /> "LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCINI793 <br /> FORM'B'(s)-1`0-11IF FOLLOWING ADDRMS. <br /> nxni OF CALIFORNIA <br /> 'TrNtM WATER RESOURCES CONTROL BOARD <br /> C/o S.W.ILF.P.s. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT-,CA WM <br />