Laserfiche WebLink
Er A"!r <br /> INSTRUCTIONS FOR OOMPIITI'ING FORM Ir <br /> GENERAL INSTRUCTIONS t f <br /> 1. One FORM"B"shall be completed for each tank for all NEW_ PERMIT"CHANGES, RINOVAi.S and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the Pi%W APPLICANT`or the LOCAL AGENCY UNDI?RGROUND TANK <br /> a _, IIVS,PI?..t:I'tJR.. <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 ITIBC <br /> 1. Mark an(X)in the ppox ngxt to the item that best describes the reason.the form is being completed. <br /> 2. Indicate ttgIGl�l4cli>lkMty name where the tank is installed. <br /> L TANK DI1,S6&4W, 4PLE`M ALL ITEM a-IF UNKNOWN-so SpEm Y N Wq"14 044 <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 tlt' s�anufactured 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 /> II. TANK CONTENTS <br /> A. 1.If MOTOR VEHICI.,1: FUEI,,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`s rvice <br /> number),if box 1 is NOT checked in A. z` <br /> �I TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BO A,P%C&D <br /> 1 Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INTERIORLINING 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 <br /> to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE7ECIION <br /> t <br /> 1. Indicate the LEAK DETECTION systcm(s) used to comply with the muni ng requirements for the tank. <br /> VF <br /> Vi: INFO"Ag1ON ON TANK PERMANLN MY CLOSED IN PIACL <br /> I. ESTIMATED DATE LAST USED-MON TH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANT`rI'Y 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 DATE TI•IE 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, thwVree digit jurisdiction <br /> number,thedi.git 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 /> 4 IT IS THE RESPONSIBH Tff OF THE LOCAL AGENCY THAT INSPEC;IS`IIJE FACILITY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS' NMBL.E FOR TIIE COMPLETION OF THE � <br /> •LOCAL AGENCY USE ONLY"INFORMAL IO FOR]FORWARDING ONE FORM"A'AND ASSOCIATED <br /> FORM-1r(s)TO THE FOLLOWING D <br /> STATE OF <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/o&W.E.F..PS. „ <br /> DATA PROCESSING C E N 71IR. <br /> P.O.BOX 527 <br />