Laserfiche WebLink
INSIRUCIIONS FOR COMPI..VnNG 41M"B" <br /> GENERAL INSTRUCTIONS. <br /> 1, One FORM"Ir shall be completed for each tank for all NEW PERMTIS,PERMTr CHANGES, REMOVAI.S and/or any <br /> other TANK INFORMKLION(MANGE. <br /> 2. This form should be completed by either the PERMIT'APPLICANt'or the LOCAL AGENCY UNDERGROUND'TANK <br /> INSPTCL'OR <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 rI'EM" <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 F=acility name where the tank is installed. <br /> I. TANK DFSCRLI"ITON-C.'OMPI17,I1?ALL,L'I1?MS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank IC)#,-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 <br /> C. Indicate the year the tank was installed(ex. 1=987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 ctc.). <br /> II. TANK CONT EMIN <br /> A. 1. If MOTOR VEHICLE FUI:;L,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUIL, check the appropriate box in section A and complete items B & D. <br /> B. Check the appropriate box. <br /> C. Check the type of MO`T'OR 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 C.A.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> W. TANK C ONSIRUCIION-MARK ONE nimONLY Y IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,, INTERIOR LINING and CORROSION PROTECIION. <br /> 2. If OTI"IER,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 011IER,print in space provided. <br /> 3. Indicate the LEAK DI I'ECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DFTW110N <br /> 1. Indicate the LEAK D1.'I'ECI1ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMAT1oN ON TANK PERMANEN11M C'IASED IN PLACE <br /> 1 ESTIMATED DA'Z'E LAST USED MOIV -I/YM- R(January, 1988 or€31/88). <br /> 2. ESTIMATED QUANTI'I:Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WrYll INERT MA'T'ERIAL?Check'Yes'or'NO'. <br /> APPLICANT'MUST SIGN AND DX1713THE FORM AS INDIC NIM. <br /> INSTRU(711ON FOR TME: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 nurober tray 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 /> 1`1'IS THE RErSPONSIBII.31'Y OF THE U)CAL AGENCY THAI'INSPECTS"IlIE FACILITY T"O VERIFY 111E <br /> ACCURACY OF TIIE INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR 7111E COMPTTIION OF 111131 <br /> "LOCAL,AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> DORM"B*(s)To 711EFOLLOWING ADDRESS. <br /> SrA1113 OF CALIFORNIA <br /> SPATE WATER RESOURCES GONIROL BOARD <br /> C/o S.W.EF P.S. <br /> DATA PROCESSING C'IWM—;R <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 90723 <br /> i i <br />