Laserfiche WebLink
INSTRUCIIONS MR COMPLETING FORM*W <br /> GENERAL INSTRUCIIONS. <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMr.M PERMIT CIIANGM REMOVAI.Sand/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI.JCAN1*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 ITEM" <br /> 1. Mark an(X)in the box next to the item thnt best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> L TANK DESCRIPTION-COMPLLqU ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank (ex.A137707189). <br /> B. Indicate the name of the company that wa-iiN" -turcd the tank A.C4E TANK NIF(.i.). <br /> C. Indicate The year the tank was installed (�x. 19,S-7). <br /> D. Indicate the tank capacity in gallons(ex. 25,YXor 10,000 etc.). <br /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE FUEL,check box I 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 CA.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> M. TANK CONSTRUCTION-MARK ONE rI7M ONLY IN BOX A,K 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 DF173MON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE IASL'USED-MOr,,rI'II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of 14AZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE IIIE FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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 11113 RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPFCT.S IIIE FACILITY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RF-SPON'SIBLE FOR THE COMPLETION OF THE <br /> *LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM'B'(s)TO ITIE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/o&WX-F-PS. - <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />