Laserfiche WebLink
INSTRUCTIONS MR COMPLAC,FORM*B* <br /> GENERAL MS-rRUCnONS- <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMr.lN,PERMIT CHANGES, REMOVAI—S and/or any <br /> other TANK.INFORMNIION CHANGE. <br /> 2. This form should be completed by either the,PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <br /> 1 Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:*MARK ONLY ONE ITIN" <br /> L 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 9r.Facility name where the tank is installed. <br /> 1. TANK DESCRII-XION.-COMPLUrIll ALI.rnRAS-IF UNKNOWN-SO SPECIFY, <br /> A. Indicate owners tank ID# - If there is a tank number that is used by the owner to identify the tank(ex,A1170789), <br /> B. Indicate the name of the compavy that manufactured the tank(ex.ACMI.',TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 11, TANK CONIIWI'S <br /> A. 1.If MOTOR VEHICLE FU 1L,check box .1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B & D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE 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 CONSTRUCTION-MARK ONE,r"? ONLY IN BOX A,B,C&D <br /> 1. Check only one item in`I'YPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> I If OTHER,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 OTHER,print in-pace provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK Df_rI1,?CTION <br /> 1. Indicate the LEAK DETECTION sr.tem(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSI0 IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTTI/YEAR(January, 1988 or 01/88). <br /> 2. FSTIMATED,QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANKInLLED WrIII INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICAN'r MUST SIGN AND DATE 7111E FORM AS INDICAIED. <br /> INSTRUCTION FOR711111 LOCAL AGENCIES <br /> The state underground storage tank identification number is composed 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 (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 /> IT IS11IE RESPONSIDII.Iff OFT1113 LOCAL AGENCY THAT INSPECTS TITE FAC31111Y TO VERIFY 7111E, <br /> ACCURACY OF 111E INFORMA'ITON. 11113 LOCAL ACY11140f IS RESPONSIBUi FOR'Ilui COMPLI11ON OF 11113 <br /> 'IMAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCINIMM <br /> FORM'11'(s)TO ITIR FOLLOWING ADDRES& <br /> STNI11 OF CALIFORNIA <br /> SEKIM WATER RF_S0URCMS CONIROL BOARD <br /> C/o&W.F.F—P.& - 11. i I ' _ . . . .,t- <br /> DATA PROCIISSING CFNf ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />