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INSTRUCTIONS FOR COMPLETING FO+Rml "B"
<br /> GENERAL gNSTRUCTION�:
<br /> l� i-y,;re EO cM 'it" sh<. ! ±.: c..r ;' +{ a rc r each tank `or a1 NEW PERMITS. PERMIT CHANGES. REMOVALS arid/or any
<br /> '"Utrt TANK INFORMATION CHANE
<br /> -Tht,; form j 1,d be omp:ot.< ' i r e i Aber' the PERMIT APPA ICA1+iT or the LOCAL.AGENCY UNDERGROUND TANK
<br /> -'"INSPECTOR,
<br /> $ 3 Pti •r tyoe of, r'' y �
<br /> nt ci�:ar! a'l re..uested information.
<br /> 4 -Use a hard pmt wr ting instrurrrrit.. you are making ;"copies:
<br /> TOP OF FORM. 'MARK ONLY ONE ITEM"
<br /> I Mark an (X) in the.box next to the item.tinat°`best describes the reason the,fdrm is,being completed.
<br /> 2 Indicate the .DBA or Faci"l ity Hemi? where .the tank ia -inStafiled: _ _
<br /> I . TANK DESCRIPTION - COMPLETE ALL ITEMS IF UNKNOWN SO SPECIFY
<br /> A. rl,ai cat. tw +er's tank,ID � I f t i;- e r C a ion: nurnber that Z.s used by the owner.to Identify the tank
<br /> (e i A��li N"p)
<br /> B Indicate the-name of the compary that manufactured the.tank (ex,. ACME TANK MFG),
<br /> C Indicate theyear"the tank was r:stalGed (ex. LYJ 7).
<br /> D. Indi cote the tangy caper i ty in u r i'i, 5 :ex 25,000 or 1{1.000 etc.). .;
<br /> II . TANK CONTENTS
<br /> A, I, If
<br /> MOTOR VFFfiICI.E 'DUEL, check box I and complete i'telirs B
<br /> tnot MOTOR VLH1(71 E F11F:(„ check the aprlropriate box iri,sect on A and complete items B & D.
<br /> B Check the appropriate' box.
<br /> C. '� C the 6T)p'c;f W)lOR Vf:,HiCFE FUEL. (if' box 1 is ch 'ckerf,in A).. :.
<br /> 0 Prrnt,.the diomica.l. name of the hazardous, substance storedin the tank and the C.A.S.#. (Chemical
<br /> Absaract Servlce number). it b�>.x 1 is NO checked ire. A.
<br /> I1I TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX- k B,,-,'!C AD:
<br /> l Check onl am Ztemf in Il`f'F t?F y�TEIi TANK MATERIAL. INTERI(3R EI ING and CORROSION PROTECTION.
<br /> 2. If U?HER, print in the space pr�)vided.
<br /> IV. PIPI t.INFORMATIbN -
<br /> r I Circle A_1f abate ground circle U ;if underground and circle bothTf applicable:
<br /> 2 If UNKNOWN' cirche, .or if OTHER, print in space provided .
<br /> 3. indicate the LEAK.OF.TEGTI"vN system(s) used to comply.,utth the monitoring requirement for the piping;
<br /> V._ TANK LEAK DETECTION
<br /> 1: Indicate the LEAK P. TECTION system(s) used th comply with :the morn tori;ng requirements for the tank.
<br /> yr: INFORMATION ON TANK PERMANENTLY CLOSET? IN P.LACE�:,
<br /> EST1M,14rED DATA' LA T.'usub - MON H YEAR (January, 1988 or 01188)
<br /> 2. ESTIMATED OUAN ITY of HAZARDOUS St18STA.NCF remaining in the tank (i=n 'Gallans).
<br /> 3 „.,WAS TANK F I L,LE.Q.,,WI1 H I NEFi i MATERIAL? Cheek Yes' or, 'NO'.__,
<br /> OPLICANIf MUST SION AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FUR THE LOCAL AGENCIES
<br /> The:State underaround-stprag.e tank ident.'ification number It ompos :fit~the two digit county number, the three,
<br /> digit 3urisdiction:- rriber;- tfie six digit facility number and the° six digit°tank number. The county and
<br /> jurisdiction number=s'a>e pcedetermined and:carr be obtained by taping the,State--Boa rd (91.6) 227-4303, The
<br /> facility number mus t1T. sarme as shown in form"A". The tank numbermay:Ase assigned by the local agency,
<br /> however', this number must be `numerical and cannot contain an alphabet. If the local agency prefers the State
<br /> Board to asstibn the-t k: er, please leave it blank: ` ' '
<br /> IT IS THE-RESPONS-IBILIT'Y O�-TME 'LOCAL AGENCY THAT:; N +ECTS THE,
<br /> ITY � '(tEftfFY=THE ACCURACY-OF THE
<br /> INFORMATION. THS LOCAL AGENCY IS RESPONSIBLE FOF( THE COMPLETION4 'THE ",LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE, FORM ".A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. 1
<br /> , , i .e a a'� •
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