Laserfiche WebLink
INS-17RUC11ONS MR COMPLLrIING FORM"B" <br /> GENIERAL INSI'RUCtIONS.- <br /> 1. One FORM"B" shall be completed for each tank for all NEW PERA41`11,PERMIT CIIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CI IANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPE(3)OR. <br /> 1 Please iYpe or Print clearly all requested information. <br /> 4. Use a hard point writing instrument.you are making 3 copies. <br /> 'I'OP OF FORM: *MARK ONLY ONE ITEM" <br /> I. 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 rmscRimoN-comPixm4 ALL rmms-IF,UNKNOWN-so spEcry <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 /> IL TANK CONTFNIN <br /> A. 1. If MOTOR VERIC1,17 FUEL, check-box 1 and complete items B& C. <br /> 2. If not MOTOR VFIIICLE FULL, check the appropriate box in section A and complete items B & D. <br /> 13. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE.I7Uf!.L(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 Sci-vice <br /> number), if box I is NOT checked in A. <br /> III. TANK CON,`;I7R1JC`11ON-MARK ONE rnim ONLY IN BOX A,It,C&D <br /> 1. Check only one item in TYPE 01'SYSIT-K'TANK MA'IMRIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the spice 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 0`111ER,print in space provided. <br /> 3. Indicate the LEAK DETECTION systems) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DINUE]ION <br /> 1. Indicate the LEAK IA11MCHON system(&) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANINII..Y CIX)SED IN PLACE <br /> 1. * ESTIMATED DATE LAST USI'D-MONTIIII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN-Iny of HAZARDOUS SUWIIANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INERT:MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DiVILI'171E FORM AS INDICATED. <br /> -MUCIION FOR'11W.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 Mard to assign the tank number,please leave it blank. <br /> ri*IS TIIE RESPONSII.311.11-f OF'11IE LOCAL AGENCY nixi-wspiicis, nw?FACILITY TO VERIFY TIIE <br /> ACCURACY OF TILE INFORMATION. 'ITIF LOCAL AGENCY IS R&SPONSIBLE FOR THE COMPLEMON OF 311E <br /> *LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM-B-(s)TO-nit!FOLLOWING ADDRESS. <br /> STNIV OF CALIFORNIA <br /> STATE WATER RESOURCE-S CONIROL BOARD <br /> CIO S.W.E.E.P.S. <br /> DATA PROCEWSING CINIT*.R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />