Laserfiche WebLink
INS`1'RUC7J7ONS FOR COMPLF�HNG FORM*Ir <br /> GENERAL INSTRUMIONS- <br /> 1. One FORINI "B"shall be completed for each tank for all NM.. PERMHS,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION C11ANGF- <br /> 2. This form should be completed by either the PERM171'APPLICAN'Tor the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC`170R. <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 VBA or Facility name where the tank is installed. <br /> 1. TANK DESCRTYLION-COMPLI:UU All,rl!ES-If?UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) #-If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <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 /> IL TANK MMIUSTIN <br /> A. 1. If MOTOR VEHICLE FUEL,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&1.). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I 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 1 is NOT checked in A. <br /> III. TANK CON517RUMON-MARK ONE ITEM ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL,INFERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING MFORMKITON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OTIIER,print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECI1ON <br /> 1. Indicate the LEAK DE'T'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INI-X)RMATION ONTANK PERMANENIT.Y CLOSED IN PLACE <br /> 1. ESTIMA'ITD DATE, LAST USED-MON`I'lI/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIAZARI)OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFFH INERT MA'IT',RIAL? Check 'Yes'or'NO'. <br /> APPLICAN'r MUST SIGN AND DATF'ITIE FORM AS INDICATED. <br /> INSTRUCTION FOR TIIE LOCAL 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 State Board to assign the tank number,please leave it blank. <br /> IT IS TILE RESPONSIBILITY 017111E IOCAL AG1.94CY 111KIANSPEC'.11 S111E FAC11X17Y 11.)VERIFY 111E <br /> ACCURACY OF 7111?INFORM)VIION. 771E LO(:AL AGENCY IS RESPONSIBLE FORTIJE COMPLIT110N OIVIIIE <br /> *I,OCAI.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A'AND ASSOCIN17ED <br /> FORM'B'(s)TO171E FOLLOWING ADDRESS. <br /> STATE,OF CALIFORNIA <br /> WNII3R VZINOURCV-S COMI'ROL BOARD <br /> C/(',)smxu�LP-S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 90723 <br />