Laserfiche WebLink
IN51'RUCIIONS FOR C OMPLEITNG FORM'B' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMI7S,PFRMrr CIEANGFS, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGF <br /> 2. Phis form should be completed by either the PERMIT'APPIICANr or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <br /> 1 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 rITM' <br /> L Mark an (X)in the t:6 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 DPSCR1PLION-COMPLE M AL1,rPFb&S-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.AB70789). <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 CONFENTS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE,FULL,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 I is NOT checked in A. <br /> BI. TANK CONSIRUCMON-MARK ONE rTEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPH OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTIIER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> I Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. if UNKNOWN.circle: or if 07IIE&print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CIOSED IN PIACI: <br /> 1. ESTIMATED DAPS LAST USED- MON171/YEAR(January, 1988 or 01/88). <br /> 2. GSIIMATED QUANITIY of ILA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MAIERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA71I TIB;FORM AS INDICAIID. <br /> INSI'RUCITON FOR IIIE LOCAL AGE?NCnLS <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 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 /> If IS11M RE?SPON.SIBILM OF 771E LOCAL.AGENCY 7IIAT INSPECTS'IIIE FACT XEY TO VERIFY TILE <br /> ACCURACY OF 111E INFORMATION. 11111 LOCAL,A(iFNCY IS RESPONSIBLE FOR 71 IF COMPLETION OF THE <br /> 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM•A•AND ASSOCIATED <br /> FORM 'B'(s)1`0111F FOLLOWING ADDRESS <br /> SPATIi OF CALIFORNIA <br /> SPATE WATER RESOURCES CONFROL BOARD <br /> C/O S.W.EF_P.S. <br /> DATA PROCESSING CFNI7?R <br /> P.O.BOX 527 <br /> PARAMOUNT-,CA 90723 <br />