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INSTRUCTIONS FOR COMPLETING FORM "B" <br /> GENERAL INSTRUCTIONS. <br /> ' . One C=ORM "8" shall be completed for each tank for all NEW PERMITS, PERMIT CHAIGES. REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by ei then he PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> V Use a hard point writing instrument, you are making 3 copies, <br /> TOP OF FORM. K ONLY ONE ITEM" <br /> I. 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 o COMPLETE ALL ITEMS - IF UNKNOWN m SO SPECIFY <br /> A. indicate owners tank I? W - If there is a tank number that is used by the owner to identify the tank <br /> (ex. AB70789). <br /> G. indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). <br /> C. Indicate the year the tank was installed d ex. 1987) , <br /> D. Indicate the tank capacity in gallons (ex. 25.000 or 10,000 etc.) <br /> I . TANK CONTENTS <br /> A. MOTOR IC I � 4" b and ^. " <br /> r�. 1 IF :'��;i;>. VEHICLE FUEL, check t.)x �. c,:l. complete items Ei � u. <br /> 2. If not MOTOR(.R t HFUEL,, `,";l eck the appropriate box in section A and complete items B & 0. <br /> B. ;'h{::ick the appropriate at box. <br /> C. Check the type of MOTOR VEHICLE Ft, (if box 1 is Checked in A). <br /> D int the er :.a name of the hazardous substance stored in the tank:. and the C.A_S,#. (Chemical <br /> Abstract Service.ce nar,E= : , . if box Ais NOl chocked in A. <br /> III . TANK CONSTRICTION - MARK ONE ITEM ONLY IN SOX A, BID C & D <br /> I. Check only one item in TYPE O SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> T if NE:t . print in the space provided <br /> IV. PIPING INFORMATION <br /> Circle A 71" ds:IOu>.- ground circle t. if underground...,',: _t.:ti, ar' Er.,<E? both if applicable. <br /> 2. If '..N*N i,,N circle or if OTHER, print in space provided <br /> 3. indicate th st' to comply;y wi`y the monitoring requirement, for the piping, <br /> V. TANK LEAK DETECTION <br /> 1. indicat., the LEAK DETECTION system(s) used to comply with tate monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK, PERM NENT.-Y CLOSED IN PLACE <br /> 1 ES IMAaTZ J LAST T U EO - M`,NIP- or 01/88) <br /> 2. ESTI WAR in the tank (in Gallons). <br /> 3. WAS .! L . . 1 10K ". Wan Yon nr ,NO <br /> APPLICANT MOST SIGN AND DATE THE FORM A.S INDICATED. <br /> INSTRUCTION FOR. THE LOCAL AGENCIES <br /> The state u vlor, in,s <dt nti l the two digit county number, the three <br /> digit jur sdi( umber. The county and <br /> jaris0atwn Quit ward 1916) 227-4303. The <br /> facility number "A", !no iArk q,aw may be assigned by the local agency, <br /> however, this mum! fiumerical wl can, Ymai n an alphabet. If the local agency prefers the State <br /> Board to assign too not, p _ave ii blank. <br /> TT Yc Tidy' nrcnnmc IBii TTN fly. a.— a ._ vim,{Fr mry '}°t IAT 'T B.sr Y �Bn"' 7 <br /> ,.4Cryr 77 7-7 .a^ir Tss 7 7 9_ , OF 77 <br /> A'4-u-w+0 :_. <br /> ..:;,-L, ;SV . II ILG,.a n A .- stSPONSIBLE FCR SHE COMPLETION OF THE 'LOCAL AGENCY USE ONLY" INFORMATION BOX <br /> AND FOR FORWARDING ONE: FORM "A" AND ASSOCIATED FORM 'B"(s) TO THE FOLLOWING ADDRESS. <br /> 0 <br />