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INSTRUCTIONS FOR COMPLETING FOR14 g,FF.
<br /> GENERAL INSTRUCTIONS:
<br /> 1. One FORM B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES. REMOVALS and/or an
<br /> other TANK INFORMATION CHANGE.
<br /> . This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR,
<br /> u. Please type or print dearly all requested information,
<br /> 4, Use a hard coint, writing instrument, you are making O cokes.
<br /> TOP OF FORM: WMARK ONLY ONE ITEM''
<br /> I. Mark an (X) in the box next to the item that best describes the reason the firm is being completed,
<br /> 2. Indicate the VBA. or Facility Brame where the tank is installed.
<br /> I, TANK DESCRIPTION - COMPLETE ALL. ITEMS u IF UNKNOWN A SO SPECIFY
<br /> A. indicate cite owners tank rD , - I f bier:" i`_. number i� t o to a
<br /> ;� � � tank rl.�+�����.., that used by ,kif�, owner ,} � ��..=i.if,y the tank
<br /> (ex A'"...yr789) .
<br /> B. °?it7C..lI.>e the
<br /> name of the company that 4'1r:1n2,(fr"acture the tank (ex, ACME TANK MFG) .
<br /> C. Indicate the year the tankwas installed (ex. 987). _
<br /> D. indicate the tank Capar'i'C',y 3C'i gailor', (ex. 15,000 or IO:O`L'ttJ etc. )
<br /> II. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL "check box I and complete items B & C. ,d
<br /> 2. + not MOTORVEHICLE FUEL, check the appropriate ate box i n section A and complete i t ems B & D.
<br /> B. a� £ kf� 1`�
<br /> Check the +a'i�i1'opr`�iate box,
<br /> C i'ek the type of MOTOR VEHICLE 1Lt (if }fY ( is viwfkvd in A)
<br /> € . Print the chemical "%'e of ml^ ha7^r ;;, 1 S.Lsi?r%e stored in the
<br /> � tirk and the C A
<br /> S (Chemical
<br /> lCal
<br /> Abstract Service number) , if box _ is NOT
<br /> checked in A,
<br /> IIIm TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. Check or.}I< one item in TYPE OF SYSTEM, ..SANK MATERIAL, INTERIOR LINING ars" CORROSION PROTECTION.
<br /> I if 01-11R, print in the space provided.
<br /> IVPIPING INFORMATION
<br /> 1. Circle A if above ground circle U if underground, and circle beth if applicable
<br /> z-1 If HNKNO-'N circle: or if OTHER, print in space provided
<br /> 3. indicate the LEAK DETECTION system(s) used to comply 4;1 the monitoring requirement e('ien.. :o"' the piping.
<br /> V. TANK LEAK DETECTION 1 66 tt
<br /> 1. ;ndic'a�, the LEAR'K D EC h , a em(s) used to comply with tt!e monitoring ngrequirements
<br /> for. the
<br /> VI s INFORMATION ON TANK PERMANENTLY SAN NT MONTH/YEAR
<br /> y `}CLOSE IN PLACE
<br /> 1. ESTIMATED DATE LAST
<br /> 2. ESTIMATED QUANTITY Ca HAZARDOUS SUBSTANCE remaining
<br /> er ir:rg in the wd.k (aa Gallons),
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check Yea or `NO
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state t,lnde>'g''"C);.ind story tankidentification 'lumber s ose r,-f j t county numb three
<br /> �.: composed� he ti�� digit I f f:i;C�Tliu, number,�". t,� w'1
<br /> digit jurisdiction number, he `ix- digit facility C1�[1=1ber` arae thesix digit tank number.. giEic')i`3..nty and h
<br /> jurisdiction numbers are predetermined an can be obtained �;='}t calling the State Board (916) 22 -4303 The
<br /> facility number must be ,he same as shown in form "A". The tank number may be assigned by the local agency,
<br /> however, this number must be numerical ic:al a=,nd cannot: contain an alphabet. If the local agency prefers the State
<br /> Board to assign the tank number. please leave It blank,
<br /> IT IS THE RESPONSIBILITY OF ITE LOCAL. AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USEONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM '°A" AND ASSOCIATED FORM "B-(s) TO THE FOLLOWING ADDRESS.
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