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INSTRUCTIONS FOR CCMP[ETING F "B" -�^~ <br /> GENERAL INSTRUCTIONS: <br /> l One FORM `'8^ shall be completed for each tank for all NEW PE0MITS, PERMIT CHANGES, REMOVALS and/Or any <br /> other TANK INFORMATION CHANGE, <br /> 3 7h1s form should be completed by either the PERMIT APPLICANT or the LOCAL PSENCY UNDERGROUND 17MK <br /> INSPECTOR, <br /> ` 3. leasa tyine or pMnt clearly all requested information, <br /> - 4 hmrd ;aoint wr1t1ng ino!rument, you are making 3 copies. <br /> - <br /> TOP OF FORM: 'Mi,�RK ONLY ONE I'll-EM" <br /> I. Mork 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 /> I . TAIK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN ~ SO SPECIFY <br /> Alndmate owners tank in # If there is a tank number that is used by the owner to identify thetank <br /> (ex 4B71789) <br /> B Indicate Lhe name of Lhe company that manufactured the' tank (ex. ACME TANK MFG), <br /> C Ind1cmLe the year the tank was 1nstalled (ex 1987) <br /> D Ind1cote the tank caVac10 1n gallons (ex 25.000 or 10,000 etc.) <br /> TT^ 7TAK CONTENTS <br /> Al IF M00 VEHICL[ FULL. check box l and cump7eLe items B Q Q <br /> 2 Jf no! MOTOR VEHICLE FUEL cheok the appropriate box in section A and complete items 8 & D <br /> B Check the awpropr1ate box <br /> C Check the type of MOTOR VEHTCL[ FUEL (1f box l is checked in A) <br /> D Print the chemical nume of the hazardous substance stored in the tank and the C.A.Sj (Chemical <br /> Abstract Serv1ce number), if box l is NOT checked in A, <br /> TTT . ' TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D <br /> l Check only one item 1n TYPE OF SYSTEM TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> ~ 2 If OTHER, print in Lhe 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 OTHER, print in space provided <br /> 3 indicate the LEAK DETECT]ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LE/Q{ DETECTION <br /> l Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED MON00E44 (January. I988 or 01/88) <br /> 2 ESTIMATED OUANTITY of H=RDOUS IU8ITANCE remaining in the tank (1n Gallons). <br /> R. TANK NK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO' <br /> PTP[TCANT MUST SIGN AND D/RE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number, the three <br /> digit jurisdiction number, the six digit facility number and the six digit tank number. The county and <br /> jurisdiction numbers are predetermined and can be obtained by calling the State Board (9I6) 227-4303 The <br /> facility number must be the same as shown in form ''A" The tank number may be assigned by the local mgenCy, <br /> hnwever, this nLimber must be numerical and cannot contain 6n alphabet. If the l0c§l agency prefers the State <br /> Board to assign the t�nk numbOr, pleo�� lebVe it blank ' <br /> IT IS ThE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br /> INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE 'LOCAL AIENCY USE ONLY" INFORMATION BOX <br /> ' AND FOR FORWARDING ONE FORM 'j~ AND QGOCIATED FORM ^S^(�) TO THE FOLLOWING ADDRESS. <br /> . <br /> ' <br /> ' <br /> '' <br />