Laserfiche WebLink
INSTRUCTIONS FOR COMPLITMAM 111" <br /> GENERAL INS`1`RUC`tIONS <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any <br /> otherTANK INFORMN17ION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECIX)R. <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 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 DESCRIPTION-COMPIZI13 ALL TIMMS-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.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 /> IT. TANK CONTFWIS <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 tankand-the C.A.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE r11W ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYS`I`EM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTE(TI1ON. <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 OTIIEK print in space provided. <br /> 3. Indicate the LEAK Di.TI`ECI'ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IXAK DFTITZTION <br /> 1. Indicate the L14AK DEI'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTI-Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USE[)-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. r-STI\β€”IA'rl--D QUANT11Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> o3. WAS TANK FILLED wrniINERT MA'rERJAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR ITIE 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 /> rl'IS THE RESPONSIRf I 11Y OF THE LOCAL AGENCY THAT INSPECTS THE FA(ILrff'TO VERIFY 11 IF, <br /> ACCURACY OF 11113 INFORMATION. 111E LOCAL AGENCY IS RESPONSIBLE FOR 71111 COMPLETION OF IIIE <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM'B'(s)TO TIIE FOLLOWING ADDRESS. <br /> STATI11 OF CALIFORNIA <br /> STATE WATER RESOURC31S COMI'ROL BOARD <br /> C/o S.W.E.F-Ps. <br /> DATA,PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />