Laserfiche WebLink
INSTRUCTIONS FOR COMPLUTING FORM*W <br /> GENERAL INSFRUCHONS' <br /> 1, One FORM"B"shall be completed for each tank for all NEW PERWIN,PERmrr CIIANGES, Rl.MOVAI-S and/or any <br /> other TANK INFORMA17ON CHANGE. <br /> 2. This form should be completed by either 0ic PERMIT APPIICA.N.I'(.)r the LOCAL AGENC7Y 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 017 FORM:'MARK ONLY ONE T11 M" <br /> 1. Mark-an (X) in the box next to the item tha�,!,cst describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DFSCRlP`17ON-COMPIZ-1111 All,ITEN[S-IF UNKNOWN-So SPaml*y <br /> A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex.A1370789). <br /> B. Indicate the name of the company that mar,!Tacturcd the tank(cx,. '.C%,'[:3"TANK MFG.), <br /> C. Indicate the year the tank was installed ((,x. '1987). <br /> D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br /> 11. TANK(XOM.wn' <br /> A. t If MOTOR V1.111CLF"FUEL,check box I 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 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 /> HL TANK CONSTRUCTION-MARK ONE rl'FM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PRO'f`E(-,I`lON. <br /> 2. 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, <br /> �print in space provided. <br /> 3, Indicate The LEAK Di31yLX-I1ON systcm(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVI*FC11ON <br /> 1. Indicate the LEAK DE-I-ECI1ON system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEM11,Y CLOSED IN PLACE <br /> J. ES'11MATED DATE LASI'USE D -MONTI.-II/YFIAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN7IT1'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INTArr MATT:RIAL? Check 'Yes'or'NO'. <br /> APPII(ANI'MUST SIGN AND D)VIE.ITtE FORM AS INDKWIT-1). <br /> INSI'RUCTION FOR THE IAX.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 /> IT IS TIIE RP—STONSIBI11TY OF TIIE LOCAL AGENCY'111NI'INSPM, N'111E FACHn-y To VERIFY TILE <br /> ACY-'URACY OF THE INFORMA`ITON. 'ITIE LOCAL AGENCY IS RESPONSIBLE FOR'ITIS COMPLE711ON OF"IE <br /> *LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM-Ir(s)TO TIIE IDIJ OWING ADDRESS. <br /> SFATH OF CA11FORNIA <br /> STATE WATER RF-SOURC-7US CON.I'ROI.BOARD <br /> C/o sm-ETIP.S. <br /> DATA PROC'ESSING 0WITiR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />