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<br /> INSTRUCTIONS
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<br /> INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS:
<br /> 1. One FORM "B`° shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any
<br /> other TANK INFORMATION CHANGE.
<br /> 2. This f,rm should be completed by either the PERMIT" APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> 3, Fl ease type or 0-int clearly all requested information,
<br /> 4. Use a hard point writing instrument, you are making u 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 faun is being completed.
<br /> 2. Indicate the CUBA or, t=acility name where the tank is installed.
<br /> I. TANK DESCRIPTION 4 COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. 1ndic;ate "wrners tank ID # If there is a tank number that is used by the owner to identify the tank
<br /> (ex. Aim
<br /> L. indica'. a of the compare that manufactured the tank (ex,. ACME TANK MFG).
<br /> C In a't. the tar;k was Ir stat °e ;ex. 198D Ir, Ir.a;.:' ca city in g,11ions ?k. z}.J.i0100 yr 10,000 etc.)
<br /> II. TANK CONTENTS
<br /> A. I TF 'tl F ~:I v t.:': tei s l i...
<br /> i r n ., �r,; ; �ate bax i n se.ai cin A and complete items B & 0.
<br /> B. C:1 e'ck the apprE
<br /> � . tvecK tte ,i ., 'd In A),
<br /> L). l'F irrt t,h,. r 1,E . . =rF_ d in the tank... and the (..A.S.#. (Chemical
<br /> Abstract Sergiice rumter . _ r'r in A.
<br /> III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> (7. -(' :.,.:fir; t.ix.., ,_r.i.!'i INTr.r IC
<br /> L. 1,=t6!eL,:+,,7ntn�uf (;::{- 7d,•_i; i:, it :. ,.tY' �,.^,�1; :.i�. �fR �1 . til f�J;�u CORROSION... PROTECTION.
<br /> 1. if OT [.R, r,P.r5r�a. "l Yl '�:-' �i p(:_e' prC i(j�:;'..A.
<br /> IU. PIPING INFORMATION
<br /> : , bt A if aeve grut nd circle urt ;r _rd Ard ,Merl- o h i a ca I:
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<br /> 3. l idi„ate the LEA, '.FTE .Y 0-: :iYStT(Si use; L;) comp y 'Wlttl t:he' monitto-Ing ream' em-rlt, far the p; ?i ng.
<br /> V. TANK LEAK DETECTION
<br /> 1. llndicatthe LEAK DETECTION system(s) E used to uotr ly ;with the nanitor ln' requirement: for the tank.
<br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> L� _ .8 - ,. t
<br /> ES.AMATE[, ji`i!i LAS'
<br /> !f,b.D _ �'Iri�YItJ,.,�, ,.l`` ��� a,...yy. �91i>t ?�`� :? ,`�UdJt
<br /> Z TTMA OtlAN 11Y to f ` `_ 'BS1 AACL r�,-.'li i r 1 'r the tank (in Gallons)
<br /> z ', TANK fILl..,..D NI.lii 1Nt_tT ?1r;TFr ?+t..? ;; Ck 'vrls' or 'NO'
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> the two digit courl't;y number, the three
<br /> d -; ar xit lank number. The county nand
<br /> Sl a _uarO t9'6) 221 43�1 5. the
<br /> T tray be assigned by the local agency.
<br /> t t.F MUs , r_ an al Jt T” the local agency prefers the State
<br /> TT 7L;. "Y"9-$-r 0rCPJftNiCI TE 7'fV r, Arzrkkry '€°€a».T s—i;Fr-r-rr ""�3 ' rarer• •r-,x 'f'n yt P.�.-a.. +pro- y.r gnan*,r F
<br /> _ ,
<br /> ,.'SPONSIB L r^OR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE A' AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.
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