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IN91'RU(TI1ON,S 17OR COMPH-1110i FORM*B*
<br /> GENERAL INSIRUCTIONS-
<br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMIT'S, PERMIT CHANGES, REMOVAI-S and/or any
<br /> other TANK IN17ORMA17ION CITAN611
<br /> 2, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> IN,SPW,170K
<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 C)11 FORM:*MARK ONLY ONE nur
<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 /> 1. TANK DESCRIP`ITON-(X)MPI.9173 ALL 1711WS-IF UNKNOWN-SO SPIWIFY
<br /> A. Indicate owners, tank ID#-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.ACMETANK Ml*-G.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> 11 Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.).
<br /> It. TANK CONTENT'S
<br /> A. 1. If MOTOR VEIIICIII.Z FUEL, 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 /> 13, Check the appropriate box.
<br /> C. Check the type of MOTOR VE.111CLE.FUEL(if box 1. is checked in A).
<br /> 1). 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 /> 111, TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C'&D
<br /> 1, Check,only one item in TYPE OF SYSTEM,TANK MATERIAL, WFERIOR LINING and CORROSION PROTIVII10N.
<br /> If 0111ER, print in the space provided.
<br /> IV: PIPING INFORMA7.11ON
<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 Ll_;AK Df-1,I'EcrION system(s)used to comply with the monitoring requirement for the piping,
<br /> V. TANK LFAK DE ITX'IION
<br /> 1. Indicate the L1,AK DF-I13(711ONsystem(s) used to comply with the monitoring requirements for the tank,
<br /> VI. INFORMATION ON TANK PERMANINILY 0.,OSED IN PLACE
<br /> 1. ESTIMATED DAIT.LAST USED -MONTTI/YFAR (January, 1988 or 01/88).
<br /> 1 E-STIMATED QUAN'ITI`Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3. WAS TALK FILL111) WITH INI.'.zKI'M. A'FE'RJAI,? Check 'Yes' or'NO'.
<br /> APPLICANT MUST'SIGN AND DATE7171F,FORM AS 1NDI(W17?D.
<br /> INSTRUCTION FOR'1111H,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 numbermustbe 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 /> Il'I5 TIfE RESPONSIBILITY OF 1111.1 LOCAL AGENCY 111JVFINSPM. N 11113 FA01TIN TO VEIRIFY11W
<br /> ACC'URACY OF*111E INFORMA7.110N. 1711H LOCAL AGENCY IS RI SPONSIBI,E FORT11E,COMPI.I.,-IION OF'ITIE
<br /> 'LOCAL AGENCY USE ONLY"INFORMAT]ION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCIN1,111)
<br /> FORM 'B'(s)'ID-11111 FOII..OWIWI ADDRESS.
<br /> STN113 OF CAIIFORNIA
<br /> STA 13 WX11,,R RESOURCUS COMROL BOARD
<br /> C/O sm.n El Ps.
<br /> DATA PROCESSING CENI'ER
<br /> P.O.13-OX 527
<br /> PARAMOUNT,CA 90723
<br />
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