Laserfiche WebLink
INSTRUCI1ONS FOR COMPLETING FORM "B" <br />GENERAL INSl'RUCIIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, RF.MOVAI S and/or any <br />other TANK INFORMATION CHANGE. <br />2. This form should be completed by either the PERMIT APPLICANT or the LOCAL 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 OF FORM: "MARK ONLY ONE ITEM" <br />1. Ma!t 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 DFSCRIPI'ION - COMPIPSM ALL M3MS - 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 />U. TANK CONTENTS <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 FULL (if box 1 is checked in A). <br />D. Print 'dic_chernipal name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br />number), i is NOT checked in A. <br />���iT:��iCr7r•�I Y7fZi1 i C�7�� �/a�:i:(i3�I:+ii Y L?T, ���►T1`i 1►f��!):-sw f��`�►7 <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <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 DETECTION system(s) used to comply with the monitoring .requirement for the piping. <br />V. 'TANK I.FAK DL?fEMON <br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PERMANENTLY CIASED IN PIACE <br />1. ESTIMATED DATE LAS`F USED - MONFH/YF;AR (January, 1988 or 01/88). <br />2. ESTIMATED QUANFITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO', <br />APPLICANT MUST SIGN AND DA IE T11M FORM AS INDICATED. <br />INSTRUCTION FOR THE 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". T7te <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 RESPONSIBILITY 017 THE LOCAs. AGENCY THAT INSPECIS TI IF. FACILITY TO VERIFY THE <br />ACCURACY OF TIM INFORMATION. 711E LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE <br />"LOCAL AGENCY USE ONI Y" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED <br />FORM "B"(s) TO THIS FOLLOWING ADDRESS, <br />STATE OF CAI..LFORNIA <br />STATE WATER RESOURCES CONI'ROI. BOARD <br />C/O smm pi & <br />DATA PROCESSING CENTER <br />P.O. BOX S27 <br />PARAMOUNT, CA 90723 <br />