Laserfiche WebLink
INSTRUCIIONS FOR COMPLI?I7NG FORM"B" <br /> GENERAL..INSTRUCIIONS: <br /> I. One FORM "B"shall be completed for each tank for all NI:1W PERMITS,PERMIT CHANGES, REMOVAIS and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2. This form should be completed by either the PERmrr APPLICANT or the IOCAI.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 ITEM" <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 /> I. TANK DESCRIPIION-COMPLIT,rE ALL ITEMS-IF UNKNOWN-SO SPEICII?Y <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 CONIIWIS <br /> A. 1.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 /> R Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUI:1L(if box'].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 /> M. TANK CONSTRUCITON-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. 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 /> 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 DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLr111CITON <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANIWII.Y CLOSET)IN PLACE <br /> 1. ESTIMATED DATE..,I.A9F USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. F,SIIMNITI)QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WZT1I INERT MATERIAL?Check 'Yes'or'NO'. <br /> APPLICANI'MUST SIGN AND DATE IIIE FORMM AS INDI(W1`ED. <br /> INSTRUCTION FOR 111E 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 Board to assign the tank number,please leave it blank. <br /> IT IS TILE RESPONSIBILITY OF ITIE IOCAL AGENCY THAT INSPECIS 11IE FACILITY TO VERIFY THE <br /> ACCURACY OF TIIE INFORMATION. TIIE LCX:AL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF IIIE <br /> *LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM VV AND ASSOCIAII?D <br /> FORM•B"(s)TO 111E FOLLOWING ADDRESS. <br /> STAIE OF CALIFORNIA <br /> S1ATE WATER RENOURCES CONIROI,BOARD <br /> C/O&W.FlE;PS. <br /> DATA PROCESSING CENJER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />