Laserfiche WebLink
INSTRUCIION S FOR COMPLETING FO19B" <br /> GENERAL INSIRUC.. ONS: <br /> 1. One FORM"I3"shall be completed for each tank for all NEW PF?RM.iTS,PE'RMI`T CHANGES, REMOVALS and/or any <br /> other'1:ANK INFORMAIION CIIANGF? <br /> 2. 'Phis form should be completed by either the PERMr1'APPLICANT or the LOCAL AGENCY U _ERGROUND TANK <br /> INSPEC['OR <br /> 3. , Please type or print clearly all-rel uested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'TOP 0I7 FORM: *MARK ONLY ONE r M* <br /> z <br /> 1. Mark 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. TANK DESC:RI "IION-C'OMPL..F E AL.I,TIIL MS-IF UNKNOWN-SO SPIN TE'Y <br /> A. Indicate owners tank 11)# -If there is a tank number that is used by the owner to identify the tank (ex.AI374789). <br /> B. Indicate the name of the company that manufactured the tank (ex. ACMP "TANK MFGC ). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> 13. Indicate the tank capacity in gallons(ex,25,000 or 10,000 etc.). <br /> H. TANK C.ONT1?N ZS <br /> A. 1.. If MOTOR VI:HJICLE?FUEL,check box 1 and complete items B & C <br /> 2.If not MOTOR VEHICLE F'U1 L,check the appropriate box in section A and complete items B & D. <br /> B. Cheek the appropriate box. <br /> C. Check the type of MOTOR VEIIICLE FUEL.(if box I 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 1.is NOT checked in A. <br /> III. TANK CON91'RUCTION-MARK ONE 1IIN ONLY IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MXI'ERIAL, INTERIOR LINING; and CORROSION PIZOTEC 1,10 . <br /> 2. If OTITER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIEIZ,print in space provided. <br /> 3. Indicate the LEAK DI TECTION systcm(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVII3CTION <br /> 1. Indicate the LIHAK DETEC'IION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANFIVIIX CLOSED IN PLACE <br /> 1. ESF`IMATED DXI'F EAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. 1?STIMA'TED QUAN 1711 Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), <br /> 3. WAS'TANK PILLED.WfI'II INEWI'M.,VrERIAI,,? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DNMI ITIE FORM AS INDICNI'ED. <br /> INSTRUC HON FOR111E LOCAL,AGENCILr.S <br /> The state underground storage tank identification number is compoSwd 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(91.6)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 nuntericat and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IW['IS THE RF°SPONSIBHXI'Y OF TIIE?LOCAL AGITNC'Y THAT INSPI T S II1E FACILITY TO VITRIFY TIIE <br /> ACCURACY OF TTIE INFORMATION. II IE LOCAL AGENCY IS RESPONSIBLE FOR IME COMPLITTION OF'[IIF? <br /> 'I.XW,AGENCY USE ONLY'INFORMATION BOX AN13 FOR FORWARDING ON]p FORM'A'AND A,SSOCINIT-0 <br /> FORM'B'(s)I`0 111E,FOI.,LOWING ADDRF SSS ..r <br /> STA'III OF C.AIAF?ORNIA. <br /> STATE wr11 ER ResouRCES CON[ROI.BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROC'FSSING CFw1T K <br /> P.O.130X 527 <br /> PARAMOUNT,CA 90723 <br />