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INSTRUCTIONS PCP COMPLETING PCPM ''B"
<br /> GENERAL INSTRUCTIONS:
<br /> I. One `_ B" sN11 be covmpleted for each tank dor. all NEN PERMITS, PERMIT CHANCES, REMOVALS ardor any
<br /> other TANK INFORMATION RMATION CHANGE,
<br /> 2. This form howl d be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> 3. Please type S� � " � clearly a� requested information.
<br /> "'3t'Cn.
<br /> 4, Use a hard,d point writing instrument, you are making 3 copies.
<br /> TOP OF FORM: 'MARK ONLY ONE
<br /> ITEM''
<br /> 1. Mark. an L Y., in the e box rex' to the item that best describes the reason the €{)rm is being ng uL:$mpl et ed,
<br /> 2. lllGi..at', ti7;? O'$rt or Facility P1aire where the tank 1t installed,
<br /> I, TANK DESCRIPTION - COMPLETE ,ALL. ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. indicate owners tank 1D # - if themis a tank number that is used by the owner to identify the tank
<br /> (ex. A370789) .
<br /> B. indicate the name of the company that manufactured the tank (ex. ACME TANK MFG),
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<br /> C. Indicate the year the tank was installed (ex, 19B&
<br /> D. indicate the; tank capacity 'i'1 gallons (ex. 25,E000 or 10,000 c. )
<br /> II, TANK CONTENTS
<br /> A. 1 . IF MOTOR VEHICLE FUEL, check box I and complete items B & C.
<br /> B. f if not MAI VEHICLE} .n .. check ck whe appropriate box it JLctio • A and complete tees 'M & 1_.T.
<br /> Check the appsopriats box.
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<br /> C Check the type of MOTOR VEHICLE ICLFUEL (if box is iec.k.,, in A).
<br /> D. Print the chemical name othe hazardous S .atrnce i �� "rthe %aC� urCthe u.A.S.# (t,hr'A?lf;al
<br /> Abstract Service e nGax'bt r). if box 1 is NOT checked in A.
<br /> IIIo TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C
<br /> Check1. ly onee,.l 3t 33 SYSTEM, TANK MATERIAL, INTERIOR LINING arECORROSION fftOL .. V 2If 07HEIR,_ print in the space provided,
<br /> IV, PIPING INFORM[ATION
<br /> . Circle `
<br /> � .. circle,ground underground, arid rrcircle both`.ri ?�� applicable,
<br /> If i 4 OTHER,
<br /> print f space provided
<br /> died
<br /> 3 indicate the LEAK DETECTION syst m .__ used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> 1. indicate the LEAK DETECTION sys t'm.5; used to comply with the monitoring requirements for he tank,
<br /> K INFORMATION ON
<br /> " KUSED
<br /> PERMANENTLY CLOSED IM PLACE
<br /> 1. ESTIMATED DATE LAS! U E D _ MONTH/YEAR r 3 y J o r ! � 8)
<br /> 1� it car'� �',' �)� �.,1
<br /> '` ST MAT D QUANTITY of �HAZARDOUS SUBSTANCE remaining it tete tank (in Gallons).
<br /> FILLED ,t
<br /> 3. WAS ACNK, S I,.�.ED WITH NEE MATERIAL?. Check Yes or NO
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED,
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground ✓t )rage tank identification number is composed of the two digit
<br /> county number, {,hkthree YF
<br /> digit jurisdiction n_.b ,
<br /> the i u fac- lay number and the six digit tank number. he 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 i form a, . The tank number may be assigned by the local agen y,
<br /> however, this ni.,mber must be numerical and cannot contain an alphabet. If the local agency prefers the State
<br /> Board to c1sC.,gn the tank number, please leave 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 AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM 'B"(s) TO THE FOLLOWING ADDRESS,
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