Laserfiche WebLink
INSI'ftl _ ONS FOR 7 NC3 FORM'Ir <br /> GENERAL rRUC'11ONS; <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERNTIN,PER rr CpII CIIt r, ItI?,MOVA S and/or any <br /> other TANK TNMR °11C)N CII NCI <br /> 2. This form should be completed by either the PE Tp App 1, r or the i3O LAC FN("X CI ItRCIRC)I)NI)'I.'A <br /> INSPIXXOR. <br /> 3. Please type or print clearly all requested infarntatian. <br /> 4. Use a hard paint writing instrurnept,, on are rupking 3 copies. <br /> TOP OF FORM:*MARK ONLYONE 111IN" <br /> 1. ;dark 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 /> k <br /> 1. TANK L)1? `R 1( ., I IL ,T All,1717ES-IF UNKNOWN-90 SPECIFY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.A B7Cl759). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME'PANIC MFG.). <br /> C. Indicate the year the tank cams installed(ex. 1957), <br /> L?. Indicate the tank capacity in gallons(ex.25,000 or 14, etc.). <br /> 1. TANKawnwrs <br /> A. L if MOTOR VE.111CLE FUF..,check box 3 and complete items I3&C. <br /> 2. If not t O`1'OR VE'l-11CLE FUEL,check the appropriate box in section A and complete items I3 & I), <br /> B. Check the appropriate box, <br /> C. Check the type of MOTOR VEHICLE FUE1(if box 1 is checked in A). <br /> I). Print the chemical name of the hazardous substance stored in the tank and the C.A.S. ,(Chemical Abstract Setvrice <br /> number), if box I is NOT checked in A. <br /> 111. TANNIC C ONS rRUCroIION-MARK ONE THIM ONLY IN IX)X A,13,C&I) <br /> 1. Check only one item in TYPE OF SYS° .M,TAMC M ATF_RIAL,INITRIOR LINING and CORROSION PRC)'I`EC7I1ON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING IM70RMAIION <br /> 1. Circle A if above ground;circle U if underground,and circle both if applicable. <br /> 2. If UNKNOWN,circle, or if Q"l:1HER,.print in space provided. <br /> 3. Indicate the LEAK DEL,TECTION system(s)cased to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK D FX—'I1C)IN <br /> L Indicate the LEAK DITIliCTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. IN[k)RMATION ONTANK PER ANEN11; (1,0S 0 IN PIACE <br /> 1. 13911MAIYD DATF I..ASI'USED-I f3N'`1-IJ/FEAR(January, 1988 or 01/55). <br /> 2. ESTIMATED QUANTITY of IIA .ARDOUS SU£3S:IA'CE remaining in the tank(in Gallons). <br /> 3. 4L'AS TANK PILI.:C )STI II INEKI' ivrERIAL?Check'Yes'or'NO'. <br /> APPLI(ANT MUST SIGN AM)DWYE IIIE p FORM&S INDIC T71). <br /> S"1'RUC"IT N 1 R."I'II1? .,AL AGENCaIJES <br /> The state underground storage tank identification number is composed of the two digit county dumber, 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 /> r usnIERF-spoNsialury o "I`w 7.. rAL AC"aENCX'IIIA`I'INT.' Ft YS 11113 FACII11Y'I`C)VERIFY11111 <br /> ACCURACY OF T11E INFORMATION.TION. °77 1?LOCALA(;I,,*N(Y IS RESPONSIBLE FOR'1111'.3(X)MP1.1?'JON OV IIIIg <br /> *IX)CAI,AGENCY USE ONLY'INFORM/010N I3OX AND 17OR FORWARDING ONE FOR 'A' I)ASS(X INI73I) <br /> FOR -Ir(s)TO 711E FO11-0 INN ADDRMS, <br /> S. <br /> SEN17 OF CAI.IIURNIA <br /> S rA'F X1`ER R11SOURCES CONFROL BOA. <br /> C/o S.WiLaps. <br /> DATA PROCESSING SSING 0, 1TrR <br /> P.O.PDX 52'7 <br /> P RAt UN ',C"A <br />