Laserfiche WebLink
-----77-��-777- <br /> • <br /> INFIRUCIIONS FOR COMP1.11c,FORM'Ir <br /> GENERAL 1N1T1'RTJC11ONS.- <br /> 1. One FOICM "B"shall be completed for each tank for all NEW PERmin's,PERMrf CITANGES, RFMOVAI-S and/or ank,, <br /> other TANK,INFORMATION C 11ANGIL <br /> 2. '17his form should be completed by either the PER.MrrAPPIJC-ANTor the LOCALAGENCY UNDERGROUND TANK <br /> INSI`FZFOR, <br /> 3. Please type or print clearly all requested information. <br /> 4� Use a hard point writing instrument,you are making 3 copies, <br /> it <br /> TOP Of'FORM."MARK ONLY ONE rlT:,W <br /> L Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> I. TANK DESCRIPTION-COM[PI13117,ALI,ITEMS-IF UNKNOWN-So SPECIFY <br /> A. Indicate owners tank 11) #-If there is a tank number that is used by the owner to identify the tank 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. 1.987). <br /> D. Indicate the tank capacity in gallons (ex.2.5,0(X)or 10,000 etc.). <br /> 11. TANK CONnINJIS t <br /> A. 1. If MOTOR VEHICLE FUEIL,check box 1. and complete items B & C. <br /> 2. If not MOTOR VE lUCLE 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 VEIRICLE FUEL(if box I 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 I is NOT checked in A. <br /> III. TANK CON,5I'RU(711ON-MARK ONE rliam ONLY IN BOX A,B,C&D <br /> 1. Check only one item inTYPE OF SYSTEM,TANK MATERIAL,INTE:1t][OR LINING and CORROSION PROTECTION. <br /> 1 If OTHER,print in the space provided. <br /> TV. PIPING INMRMA711ON <br /> L Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTIIER,print in space provided. <br /> 3. Indicate the LEAK DETECI`ION system(s)used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK D131'EC717ON <br /> 1. Indicate the LEAK DETECI'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENrI1.Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST'USED -MONHI/YEAR(January, I'M or 01/88). <br /> 2. ESTIMATED QUANTrl'Y of IIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> I �, <br /> 3. WAS'TANK FILLED WITH INE16'MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANI'MUST'SIGN AND DA7.11i'llIE FORM AS INDI(WIED. <br /> iN,srRuC'I`ION FOR 111H 1.00k],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 maybe 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 leaven blank. <br /> ITIS'nIE RKSPONSIB111TY 0111111.1 LOCAL FACIIXITTO VERIFY THE <br /> ACCURACY 0171111i INFORMATION. TIIF LOCAs,AGV,NC`Y IS R11-SPONSIRIT.FOR1711E.COMPLITI[ION OF 771E <br /> *LOCAL AGFNCY USE ONLY"INFORN4/VI10N-I-V))' NNH) FOR FORWARDING ONE FORM'A"AND ARSOCIA71TU) <br /> FORM TIIU FOLI-OWINC,ADDRESS. <br /> STATE 017 CAIIFORNIA <br /> STNITI*WNII.?R RESOURCES CONIROL HOARD <br /> C/o S.W.E.&P.s. <br /> DATA PROCESSING C.TWIT,,R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />