BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS FOR COMPLETING 140"B" • GENERAL INSTRUCTIONS: I. , One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT,CHANGES,-.REMOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL.AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making'A copies. T'OP OF FORM:"MARK ONLY ONE rme 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK DESCRIPTION-COMPLE,ALL ITEMS-IF UNKNOWN-SO SPECIFY . A. indicate owners tank ID# -If there is a tank numher that is used by the owner to identify the tank (ex.AB"9). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). It. TANK CONTENTS A. 1.If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if-box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tan"nd-the CA.S.#. (Chemical Abstract Service number),if box 1 is NOT checked in A. 4TU TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, IIv TERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION . 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DETECTION system(s)used-to comply with the monitoring requirement for the piping. V. TANKTEAK DETECTION 1. -Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTUSED-MONTH/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTH'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). - 3. WAS TANK FILLED WII7i INERT MATERIAL.? Check'Yes' or'NO'. APPLICANT MUST SIGN AND DA1E 111E FORM AS INDICATED. INS I'RUCMON FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction. number,the sive digit facility number and thesixdigit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in form"A". The tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT'INSPECTS THE FACRM T'O VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR INE COMPLETION OF 771E RACAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. STALE OF CALIFORNIA STATE WATER RESOURCI+S CONTROL.BOARD C/O S.WEEr P.S DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723