Laserfiche WebLink
• i <br /> INSFRUCIIONs FOR COMPLI117ING FORM'B" <br /> GENERAL 1Ns1'Ruc;CIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERNUF CHANGES, R1 MOVAI S and/or any <br /> other TANK INIAORMATION 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 rfEM' <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 DFSCRIPIION-COMPLI W.ALL 1711MS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank Ill #-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 CONTENTS <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& 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 /> III. TANK C.ONSTRUCIION-MARK ONE YW-M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INI:'ERIOR LINING and CORROSION PROTNC'I1ON. <br /> 2. If O'TI1E11,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 LAK DE-ITZ17ION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INI1ORMAIION ON TANK PHRMANFNI7 Y CLOSED IN PLACE? <br /> 1. ESTIMATED DATE IAS:['USED-MON:I'H/YEAR(January, 1988. or 01/88). <br /> 2. FSI:'IMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFIII INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA11?T1I1?FORM AS INDIC M0. <br /> IIKSTRUCrION FOR THE;LOCAI.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 17HI Ri:NPONSII3ILITY OF TuE LOCAL AGF NC:Y THAT INSPECTS 111E FAC.ILrff TO VERIFY TME <br /> ACCURACY OF THE INFORMA110N. TILE LOCAL AL AGENCY IS RFSPONSIBI..E FOR 111I1 COMPLETION OF THF? <br /> *LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIA111113 <br /> FORM 91'(s)TO TIIE FOLLOWING ADDRESS. <br /> STATE OF CA11FORNIA <br /> 917111E WATER RESOURCES CONTROL BOARD <br /> C/O S.Wiu P.S. <br /> D)V rA PROCESSING C EN11?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />