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, <br /> 0 <br /> 0 <br /> _ <br /> INSTRUCTIONS FOR COMPLETING FORM "B" ~ <br /> GENERAL INSTRUCTIONS: <br /> � One FORM ^B'' shall be completed for each tank for all NEW PERMITS. PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2 This form should be completed by either the PERMIT APPLICANT or the LCCAL AZENCY UNDERGROUND 770K <br /> ANSPECTOK <br /> 3. Please type or print clearly all requested information. <br /> 4. Use 8 hard point writing instrument, you are making 3 copies, , , <br /> TOP OF FORM: 'MARK ONLY ONE ITEM" <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 DSA or Facility name where the tank is installed. ` <br /> T^ TANK DESCRIPTION - COMPLETE ALL ITEMS ' IF UNKNOWN ' SO SPECIFY <br /> A indicate owners tank IO # If there is 3 tank number that is used by the owner to identify the tank <br /> (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 I0.000 etc.) <br /> TT. TANK CONTENTS <br /> A l IF MOTOR VEHICLE FUEL, check box l 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 /> BCheck the appropriate box. <br /> C Check the type of MOTOR VEHICLE FUEL (if box l is checkeU in A) <br /> D Print the chemical name of the hazardous substance stored in the tank and the C A.Sf (Chemical <br /> Abstract Service number), if box I is NOT checked in A <br /> TT7 . TANK CONSTRUCTION - MARK ONE {TEM ONLY IN BOX A, B` C & D <br /> l Check only one item in TYPE OF SYSTEM, TANK MATERIAL. INTERIOR LINING and CORROSION PROTECTION. <br /> 2 If OTHER, print in the space provided, <br /> Ty. PIPING INFORMATION <br /> l Circle A if above ground circle U if underground, and circle both if applicable, <br /> 2 <br /> If UNKNOWN circle: or if OTHERprint in space provided <br /> 3 indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DETECTION <br /> l indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VT. TNFORMATTON 'CIN TANK PERMANENTLY CLOSED IN PLACE <br /> l ESTIMATED DATE LAST USED MONTH/YEAR (January, 1988 or 01/38) <br /> 2 ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (1n Gallons), <br /> 3 WAS TANK FILLED WITH INERT 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 storage tank identification number is composed of the two digit county number' theAhree <br /> digit jurisdiction number, the six digit facility number and the six digit tank number. The county and <br /> jurisdiction numbers are predeterm1ned and can be nbtonned by calling the State Board (8I6) 227-4303 The <br /> facility number must be the same as shown in form ^A^ The tank number may be assigned by the local agency, <br /> however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State <br /> Board to assign 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 /> iNFOR;ATION. THE LOCAL ALENCY IS RESPONSIBLE FOR T&COMPLETION OF THE 'LOCAL AGENCY USE ONLY" INFORMATION BOX <br /> AND FOR FORWARDING ONE FORM ^A^ AND ASSOCIATED FORM ~B^(m) TO THE FOLLOWING.ADORESS. <br /> ` ��. � <br />