|
INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INs"rRUCTIONS:
<br /> 1.. r r M r.' E be eaCh t�EI,J, or, all NEW PERMITS, PERMIT CHANGES. REMOVALS arEd/or, arl.`y
<br /> IANK INFORMATION CHAAIGE,
<br /> 2, T n I , f h, ,d b Tf;'r ID y:,_' V,", PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR
<br /> " P e,a se'' vpe t,r p-it"1 ,:E�.,F,�'„ .�;f':t"`i;#r3�i".3 1.
<br /> Hs(,,,., ,; '.. po f }€t. twr st" E 4:? T i...rl
<br /> TOP OF FORM: 'MARK ONLY ONE ITEM"
<br /> I. Mark ay X) in the b,,ux next to t he item that hest allescribes the C't?c;son the form is beiniw-+ cofyllp',;eted
<br /> 2, Indicate t #L', DBA or Fac—: 1 ity 1'€u'me wherc, tho tank is installed.
<br /> Ia TANK DESCRIPTION - COMPLETE ALL ITEMS a IF UNKNOWN - SO SPECIFY
<br /> A, Indicateowners tank .iD � - 1.f there is a € er^ '' �s s the t
<br /> ,.. .'`ci a `I USf,. Vii}% 1i� JvInPY' to identify the tar'1€K
<br /> B. lnu"icate the name of
<br /> the companyt #I. rlant.'%ctE "ed t� tufK ;eX, ACMETANK ,..
<br /> C Il"('d:Cate the !{?-r'.' "the tank was 11'lr`.l,u: led (ex •��t 000
<br /> �
<br /> +h e ! n 7� r� 1 a r":( R v '`.7�" 1 t' 1, '} . 1 V,:3�!..� etc,1
<br /> Li Indicate 1.1 i1, i, liA ca-a—E,�Y n {t} E�l (t�,'�x, t�.:s ��(�0 or €# lytc 'I
<br /> IIx TANK CONTENTS
<br /> A. i 1Y MOTNI VF]HIt..C...'w °t.cl , Cpeck box 1. and :.0111;)1nte it'PMS 8 & C.
<br /> L. 1triot N %EOR x''E.Nlt,1.1 FUTL, check the app)ror,.."ri tt;P., box in section A and complete `It":'ms B D.
<br /> B. Ch e c tht� >pif'Op:iC`l;t:p; 70X.
<br /> (.�leck the tj 1pe of i"ir:�Or) vFli! 1..�. 'L.C. ' i f �}(X .L is rIi '�w 13 A).
<br /> 1. p'r?r"t; the dr1emical namiie of' lLhe hazar'`o sulbstance stored Irl the tank and the ; .A.S.#, (ChemicalAbstract Sei vice �lzr,be;„ ;f ;rY is NOT >�#ECket1 inA,
<br /> III a TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, IIQ C
<br /> .�.. . s "�J� } TANK �ftYRTpINTERIOR I IN N� d :E CORROSION
<br /> pRlT �'.i�.IihN
<br /> .( Frck vr1Y one �aFr7r
<br /> 2. ,.l
<br /> print n the e prov i ded,
<br /> IVPIPING INFORMATION
<br /> z. A t �' r.d i-r:C( ( r, r ( :#r a wits i rl It rr rlrt tix..
<br /> �. I t € r`hp€ �l .,. Ire L r j€ ' i r E c f' �'r v'. t .,..
<br /> LLak Lill{�.`.... .a ", , ,i t p.,ly rVlt a} � r1C� f7't:v'"?Yz,? I:EE �;;. tom., �� �1 ,r7,
<br /> p pl
<br /> V.
<br /> TANK LEAK DETECTION
<br /> i., r icl €Fe 9'.h t.1 K L.L IEr'i 10 N ,,rs j' .. ra) us, ;1 i.rc) romni" w t;n the fionitcr,inC,i "E'.�G'r'f'('1er1,... �-t:r, tiara tank,
<br /> VI , INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> I1 L-,Sl US;1J` r'rO IH- Y yr (..r tQR .,r. t �1
<br /> i. 3 aa p i. :Jc". l!<c,i8 its 8..r
<br /> ., 1 ML`. 4.NT }€.lAN I � E` �" �.t (M1 (1 l �"�fl �i 'Ga: � 1 a r Gallons),.E r._r it r r€ the an*k (in Gallons),
<br /> W_S _ANK Frt[.�? ;l ri .Pd t.s M . ,. ",, . ('heck_� k `.t> c?E N;�
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED,
<br /> INSTRUCTION FOR THE LOCAL. AGENCIES
<br /> at, t uride ri o.i ncd Ct}r`a i,1� .ar',k .t-.'# #ca l t "'r s El i n o r
<br /> �` br number l ';C#3) 4 "'i� t�"!c' t�� ;�tt county C1�sT'.r�i", t.ptf? th'�F?c
<br /> t, ,l 1r"`s i ct,#o nu ibe i i`l(` a l,R �` tt s '� 3 s y t"? i rE F- r€ the i i x d1 .I i t tank rlLa;l°.t3f??^. The county iir#r;
<br /> !Llr'i`.dirt7 ar r ma �E )r. .eE t 1id and �t 7e obtain-a.'
<br /> b La 1n t„S : E �rq i�" State r �;1�)<,2#2743ra
<br /> 1
<br /> . -halocal agency,st be vie, Y.r t l .v M rl! A he tank nivibemay r� assigned 'Civ3a
<br /> -1 ,his
<br /> ic, I a no 'C'a n no 1, contari an alphabetIf the local agencY prefers the State
<br /> Boar',. to a sian the ank nurrit-er. polease leave It blank,
<br /> IT IS THE RESPONSIBILITY OF THE 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 USE ONLY” INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.
<br />
|