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INSTRUCTIONS FOR. COMPLETING FORM $,B"
<br /> GENERAL INSTRUCTIONS:
<br /> 1 . One FORM "B" shall be completed for each tank forall NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any
<br /> other TANK INFORMATION CHANGE.
<br /> 2. This fi-,;rm should be completed by e3then the PERMIT APPLICANT"or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> 3. 'lea'se, tyre or print clearly al requested information.
<br /> 4. Use a hard point, writing instrument, you are ma0 rtg 3 copies.
<br /> TOP OF FORM, 'MARK ONLY ONE ITEM"
<br /> 1. Mark an (X) in the box next to the item that hest 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 - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. .rid1<; owners tank ID If "h'er'e is � tank number that is used by the owner t, identify
<br /> the tank
<br /> B. Irid:. . of, the company that marlafacturGU the tank (ex, ACME TANK MFG).
<br /> C In. , thetire, was Ins, al F?1 ;E'k 19s3
<br /> C . Ind E r ga` ion s (,,�x 25.000 or 10,000 (,,,tc.)
<br /> I . TANK CONTENTS
<br /> A q p ,.j'i 7. ( 7 n }
<br /> A{ .A. IF�-Ii.OR L(..HICi...I.�_ FUEL, i�'E`�'�" Ai`✓'k. E n€:, I,Mil-oiC.ie items B g
<br /> 2. if n;t r+ull`.) .'E:I .. FiliL, ch:_,k `fi a r; r'ia e k�ax in. e tion x and complete items i3 & D.
<br /> B. Check theDry rr air, '. ._ >x.
<br /> -_
<br /> F ." "E"a`..�_.. t3 i..:... (€ ' ,�:/:<. z 'S Cf1£'CkeC! 7?1 Ai.
<br /> itirC' ;t'rG ' ... the tcrfand fe C,A.S
<br /> (Chem7calD, Pri`nt3thhazacus ua
<br /> is NOT rhe eked j Y1 A.
<br /> III , TANK: CONSTRUCTION - MARK ONE ITEM ONLY IN BOX AR B, C & D
<br /> 1. 3- *\ A �^ Fi T (� T f` .-I f hr• ^TTON
<br /> Nr DoT
<br /> (--I, ,nll one jt-` € i"€ TVP-- `t" 'fit': i. fi; �.. x tiTL.R'OR _ 1 � S anti t,v'�Yt�,SION R Y.L '�v.
<br /> ; 111' In t lie spaiCe pruvl ed,
<br /> IV. PIPING INFORMATION
<br /> 1:. Cinch) A if above ground circle U und—ground. and ;J rcle, both if applicable.
<br /> 2. If UNKNOWN circleor i t 01HER. r.3. in s z Enov, d
<br /> F 'i.... e C'. V'
<br /> 1 licai.e the LEAK iFli. t:?.r"E.,i 1 _ J tri conn iy with the, monit.oring requirement for the pining.
<br /> V. TANK LEAK DETECTION
<br /> yY i e E DETd-T ��i' System,""; ') iY Y 4l P• Jr �i
<br /> 1 . �R �.a=,.. the LEAK yst E. .:A to e of ly beth: the rrie,.EiL., �g 'car � c>mc €ts �v the tank.
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PUCE
<br /> T L.t'.AR,`J E'il 11,iL LASI =,I F0 .. M t"'<!Y, r": :ii 't✓} (�" i)R f�*'>)
<br /> 2. 'S l'.M,-i ?3uAN`1_l Y f H iZARD0 r S,;, S l illlil,l_ r in the ?tank (in Gallons).
<br /> 3, WAS TANK FILLED 111H INERT MATFRIAL? 1,^%C,� Er 'NO'
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> Tfin ,Ewe 0in ;r sit ?,r;f' two digit, county number, the three
<br /> tank number. T}`
<br /> The cnu ,4 ano
<br /> "
<br /> t]E.,�. ,ij t. L (J'_C)r G.,l..i `I.y' T-t int'
<br /> may be. assigned by the local agency,
<br /> howe`- this r ani 1.
<br /> the l coca l agency prefers the State
<br /> Bf,iartt ass ign ii .
<br /> TT T� -"X DrcmnNMIBI ,J it' PR -Y-1yn . n ' AvF e„
<br /> {^^
<br /> LETION Or THE LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM "A' AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.
<br />
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