Laserfiche WebLink
IP <br /> INSI'RUCIIONS FOR COMPLETING FORM'B" <br /> GENERAL INS-MUC17IONS- <br /> L One FORM"B"shall be completed for each tank for all NEW PERMT17S,PFRmrr CHANGES, REMOVALS and/or any <br /> otherTANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERmrr APPLICANT 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 HEW <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 or Facility name where the tank is installed. <br /> 1. TANK DHSCRW17ON-COMPLE7111 ALL riLIMS-IF UNKNOWN-SO SPFX317Y <br /> A. Indicate owners tank 10 #-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.ACMETANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> 1). Indicate the tank capacity in gallons (ex.25,000 or 10,(1(10 etc.). <br /> 11. TANK CONITWIN <br /> A. I.If MOTOR VEHICLE FUEL,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 & 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VE 111CLE <br /> ' FUEL(if box 1. is checked in A). <br /> I <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 I is NOT checked in A. <br /> 111. TANK CON1,;rRUCf7ON-MARK ONE 1711M ONLY IN-BOX N B,C&1) <br /> 1- __ <br /> 1. Check only one item in TYPE,OF SYSTEM,TANK MA'ITRIAI.,,INTFRIOR LINING and CORROSION PROTECIION. <br /> 2. If OITIF 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 it OTHER,print 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 DE`rEC`I1ON <br /> 1. Indicate the LEAK DE, <br /> 1T'ECf`ION system(s) used to comply with the monitoring requirements for the tank. <br /> V1 INFORMATION ON TANK PERMAN17MI'LY(MOSED IN PLACE <br /> I.. ES flMNIT-0 DATE LAST USED-MONl"I1/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wrrn INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE ITIE FORM AS INDICATED. <br /> INSTRUCTION FOR T111?LOCAL AGENCIES <br /> The state underground storage tank identificatiod 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 Ulf',RESPONSIBIIJTY OF 111E.LOCAL AGENCY'11IAT IN%Pl3CfS'IIIE FAC111TY11)VERIFY 11111 <br /> ACCURACY OF TIIF INFORMA'110N. `111E LOCAL AGENCY IS RESPONSIBLE FOR 1111.1 comipufnON OF ITTE <br /> 'LOCAL A013NCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM*A*AND ASSOCIA110 <br /> FORM-Ir(s)110`111F,FOLLOWING ADDRESS. <br /> S1'WfE OF CALIFORNIA <br /> SMATE,WA MR RESOURCES CONTROL BOARD <br /> • C/o&W.I1yi,.P_& <br /> DATA PROCESSING CTNMiR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> 0 <br />