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INI;t'RUCIIONS FOR COMP112VICi DORM*B* <br /> GENERAL,INS-IRUC-FIONS- <br /> t One FORM"B"shall be completed for each tank for all NEW PERM11'S,PERMIT CIIANGES, REMOVAI—S and./or any <br /> other TANK INITORMAIION CHANGE. <br /> 1 This form should be completed by either the PERMIT'APPLICAMI'or the LOCAL 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 m4w <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 1 Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DESCRIFI'ION-(X)MMIUM ALL r11WS-117 UNKNOWN-SO SPECIFY <br /> A. Indicate owner-,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.ACMETANK 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 /> 11. TANK CONIENIS <br /> A. 1. If MOTOR VEHICLF.FUEL,check box I 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 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 I is NOT checked in A. <br /> 111, TANK CONSTRUC!IION-MARK ONE 1111M ONLY IN 10X A,B,C'&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MNFERIAL, INIMRIOR LINING and CORROSION PRO'f`ECrlON. <br /> 2, If OTIIEI2, print in the space provided. <br /> IV. PIPING INFORMATION <br /> L Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 1 If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DI IECTIJON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLrI*V(7IION <br /> L Indicate the LEAK DETEC'11ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMNIION ON TANK PI RMANINILY CLOSED IN PLACE <br /> 1. ESTIMATL,',D DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2, ESTIMATED QUAiarry of jIAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wITI-1 INERr mAFFRIAL? Check 'Yes'or'NO'. <br /> APPLRAW MUST SIGN AND T)NM7'17111 FORM AS INDI(WITI-D. <br /> 1NSTRUC11ON FOR7111.1 I.,OCAL AGENCIF—S <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 pre&termined 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 Sta*e 13oard to assign the tank number,please leave it blank. <br /> H'ISITIE RESPONSIBUXI'Y OF 1111.1 LOCAL AGENCY 111ATINSPIX7M'11113 FACILITY TO VERIFYITIE <br /> ACCURACY OFIIIE INFORM/010N. 111E IO(AL AGEN(Y IS RESPONSIBLE POR 1.11E COMPI.E.11ON OF IIIE <br /> *I,O(AL AGENCY USE ONLY"INMRMNIION BOX AND FOR FORWARDING ONE FORM*A"AND ASSO(-1ATFD <br /> FORM-1r(s)1`0111B FOH OWING ADDRESS. <br /> STXIIOF CALIFORNIA <br /> SVVIII WATER RESOURCES CONTROL BOARD <br /> C/O&W.E.E.P.S. <br /> DATA PRO(MSSING CENrER <br /> P.O.13OX 527 <br /> PARAMOUNT,CA 90723 <br />