Laserfiche WebLink
J <br />IN91'RUCTTONS FOR COMPI.J?1T . FORM "B" <br />C�FNERAL INSTRUCTIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMrr CHANGES, REMOVALS and/or any <br />other TANK INFORMATION CHANGE. <br />2. This form should be completed by either the PERMIT APPIICANI7 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. 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 />1. TANK Di?SCRIP'1TON - COMPLU17-1 ALI, I71?.MS - B+ UNKNOWN - SO SPECIFY <br />A. Indicate owner; 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 />H. 'TANK CONTENTS <br />A. 1. If MOTOR VEHICLE FUEL, check box 1 and complete items B & C. <br />2. If not MOTOR VEHICLE' FUM., 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 T'UEI.. (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 Service <br />number), if box I is NOT checked in A. <br />III. TANK CONSI'RUCITON - MARK ONE ITEM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, 'TANK MATERIAL, INFERIOR LINING and CORROSION PROTECTION. <br />2. If OITIER, print in the space provided. <br />IV. P.IPINOINPORMATION <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 DEI'ECFION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DLTF.(:11ON <br />1. Indicate the LEAK DEM ECFION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFX)RMATION ON TANK PERMANI NI7 Y C IA) iED IN PLACE <br />1. ESTIMATED DA11" LAST USED - MONTII/YEAR (January, 1.988 or 01/88). <br />2. ESTIMATED QUAN7PI"Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MNITRIAL? Check 'Yes' or 'NO'. <br />APPLICANT MUST SIGN AND DATE MIR FORM A.S INDICTED. <br />INSTRUC11ON FOR TIIE I.,OC:AI. 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". 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 Sta+e Board to assign the tank number, please leave it blank. <br />rI' IS THE RESPONSIBILITY OF 11111? LOCAI. AGENCY TIIAI' INSPI:+Cl';i THE FAC1IXI'Y TO VERIFY 111E <br />ACCURACY 0117111E INFORMATION. MIE LOCAL AGENCY IS RESPONSIBLE FOR 111E COMP11i11ON OF 111E <br />"LOCAL AGENCY USE ONLY" INFORMAIiON BOX AND FOR FORWARDING ONE FORM "A" AND AS.SOCIN1111) <br />FORM "B"(s) TO 711111; FOLLOWING ADDRESS. <br />STATE OF CALIFORNIA <br />STATE WATER RFSOURCHS CONTROL BOARD <br />C/O &W.E.E.P.S. <br />DATA PROCESSING CENTER <br />P.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />