Laserfiche WebLink
INSTRUCTIONS FOR C OMPLEIING FORM-B- <br /> GENERAL INSTRUCTIONS- <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMIIS,PERMIT CITANGES, RI MOVAI S and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAI,AGENCY UNDERGROUND TANK <br /> INSPECTOR <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 017 FORM:*MARK ONLY ONE I11W <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 /> L TANK DFSCRIF17ON-COMPI.EIL AIT.ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank Ill# - If there is a tank number that is used by the owner to identify the tank(ex.AI170789). <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 /> 1I. TANK C'ONTFIM <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 tank and the C.A.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OFSYSTEM,TANK MATERIAL,IN'T'ERIOR LINING and CORROSION PRO'I71,CI'ION. <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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DFTECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENI7 Y CI.CM0 IN PLACE <br /> 1. ESTIMATED DATE LAST'USED-MONI'H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANITTY of I-IAIARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 171E FORM AS INDICATED. <br /> INSTRUCTION FOR TILE LOCAI.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 /> IT IS THE RESPONSIBHXI*Y OF 1III3 LOCAL AGENCY 17IAT INSPECTS 11113 FACILITY TO VERIFY 1IIE <br /> ACCURACY OF THE INFORMATION. TIE UOC'AL AGENCY IS RESPONSIBLE FOR TILE C.'OMPLEIION OF TILE <br /> -IACAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOC KI13D <br /> FORM-B-(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONI'ROI.BOARD <br /> C/O S.W.EE P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90'M <br />