Laserfiche WebLink
4 <br /> INSI'RUCIIONS FOR COMPI.I?'ITN FORM"Ii* <br /> GEM?RAI.IW,FRUCTIONS: <br /> 1. One FORM"S"shall be completed for each tank for all NEW PERMI'T'S,PERMCI'C IIANGIS, REMOVAI S and/or anv <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMCI'APPLICANI'or the LOCAL.AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. 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 1T3.m <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 DSA or Facility name where the tank is installed. <br /> 1. TANK DL SCRIPIION-C OMPLUIL:ALL.111,4MS-IF UNMOWN-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.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME 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 /> II. 'TANK CONITNLS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2.If.not MOTOR VEIIICI,E FUEL.,,check the appropriate box in section A and complete items B& D. <br /> S. Check the appropriate box. <br /> C. Check the type of MOTOR VEsIIICII FUEL(if box 1. 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 CONSTRUCIION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSI'FM,TANK MA'ITRIAL,INI'ERIOR LINING and CORROSION Plzou::"cnON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> L 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 DEFECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE`FFC CION <br /> 1. Indicate the LEAK DETTCTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMAT 11ON ON TANK PERMANENILY CI()~SED IN PIACI <br /> L ES'TIMATT?D DATE,LAST USED-MONTII/YEAR(January, 1.988 or 01/88). <br /> 2. EB:CIMATED QUANITI'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WPTH INERT MA":ITRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA1111 THE FORM AS INDI(WIFD. <br /> IWI'RUCLZON FOR 77113,LDC:AL 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 /> rI'IS THE RISPONSIBII TI.'Y OF 111E I,OC'.AL.AGENCY THATINSPECTS 731E FACTLITY TC?VERITY T1IE <br /> ACCURACY OF'I'IIE INPORMAIION. TIIE LOCAL AGENCY IS RESPONSIBI.d?FUR TIIE COMPI.I L1ON OF ITIE <br /> 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCIAITD <br /> FORM*I3"(s)TC)TIIE FOIL OWING ADDRESS. <br /> STA'I3:OF C.AIJFORNIA <br /> SUVIII WA1TR RFSOURCES CONTROL HOARD <br /> C/O S.W.F E.P.S. <br /> DATA PROCESSING CE:NITR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />