Laserfiche WebLink
INSTRUCTIONS FOR C OMPI.H1'Itt3C, FORM"I3" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PE RMII:S,PERMrr C:IIANGI°.S, REMOVAI:S and/or any <br /> other'1:ANK INF ORMA'IION CHANGE? <br /> 2. This form should be completed by either the PERMIT APPi..jcttrT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECI'OR. <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 r1I4M" <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 DBA or Facility name where, the tank is installed. <br /> 1. TANK DESC:RIP1'ION-C OMPLETL ALL r1`EMS-1P UNKNOWN-SO SPI 'FY <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 /> H. 'TANK CONI1?NIIS <br /> A. 1. If MOTOR VEHICLE"FUEL,check box 1 and complete items B K C. <br /> 2. If.not MOTOR VEIIIC1,13'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 VEMICI.,I 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 AbstractService <br /> number),if box 1 is NOT checked in A. <br /> III. TANK G'ONSTRUCTION-MARK ONE ITEM ONLY IN I3OX A,B,C&D <br /> 1. Check only one item in TYPE OF SY91'L3M,TANK MATERIAL, INTERIOR LINING and CORROSION PRO'I1?Cl'IC)N. <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,print in space provided. <br /> 3. Indicate the LEAK I.M 11"C'11ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETF.(,`IION <br /> 1. Indicate the LEAK DF;I}C'TION systenr(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON'TANK PERMANEMILY CI,C)SED IN PLACE <br /> 1. E5TIMAII',D DA"TL:i L.A91'US1.D -MONTII/YEAR,(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HA%ARI)OUS SUBSIANCE' remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITEI IN1 R'I'MA'I'F.'RIAL? Check 'Yes'or'NO'. <br /> APPLKANT MUST SIGN AND I)AI13'17113 FORM AS INDICAITD. <br /> 1W17RUCL'ION FOR TILEi 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 Sta+e I.Wrd to assign the tank number,please leave it blank. <br /> rI'IS'ruE RFSPONSQ3Iurf OF 111E LO AL.AGLNCY'11INF INSPECTS ITIE FACHXIT TO VERII"V 11-11E <br /> ACCURACY 0F17IE INFORMA11ON. THE LOCAL AGENCY IS RL'SPONSIBI,E FOR'I1IE COMPI.1:I1ON OF 111E <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSO(IAIED <br /> FORM "B"(s)TO'171113 FOL LOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STSFE WATER RESOURCES C X)MI ROT.BOARD <br /> C/o S.W.LiF P.S. <br /> DATA PROCESSING C:ENIT:R <br /> P.O.BOX 527 <br /> PARAMOUNF,CA 9072+3 <br /> ZY, <br /> sa <br />