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INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENE#,,I T'RUCI IONS: < :.
<br /> 1 (?ne f',Rm "B•` shat-1 he or, ear h no for all NEW PERMITS', PERMIT CHANGES, REMOVALS and/or any
<br /> c,11her TANK .INFORMATION CHANGE a
<br /> 2: This fiorm",rtr„uld be nompletod ly tiith4r the PERMIT AFPLICAN?-ortie LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR„
<br /> 3 PiEa�''t,Y f. C .p l,rlt cieilr'ly as i rtgUeSfed infortnati:On.
<br /> 4 Use a�hard-p iort-writing instrument.. you,-are-mak-i ng '3 copies.
<br /> i t _ • .
<br /> TOP OF."FORM MARK ONLY'ONE ITEM
<br /> I Mark an (x) in the box next to the item that best describes the reason the form is being completed.
<br /> 2 Indicate t.hc.f)B1 or• facilii;y namo where the tank is installed..
<br /> 'TANK DESCRIPTION `iCOMPLETE ALL ITEMS' IF UNKNOWN --:56 SPEC Irl
<br /> A. 14 icaI cw ,E� s tack. 1D # If tt : isJi, tarsk: ntarnber ttrat is used:by the owner to identify the tank
<br /> (ex.
<br /> AI;
<br /> IC'u9t r .
<br /> B indicate the namE of t°he ccmpany that marlUfactured tfie- tank (ex., ACME TASK MFG).
<br /> C. Indicate, the -rear the tank was inst.olled. Qx. 1987).'
<br /> D Indicate the tarp.capar:.i ty i n Ual l urts (ex__4 ,25;000 or 1000 etc.),
<br /> II. TANK CONTENTS ;.
<br /> A. 1. 11' Mi?TOR VEHICIT FITS: check box 1 and cgmplete.itetii ' �`& C,
<br /> 2. ;f not MOTOR VLHICI t. t,lf cher.k kse appropriate box .r.n..sec-t®ion A and complete items .B & D.
<br /> H 'Check thij aljpropri at box.
<br /> C ("heck the type of Mow VE.fiICI E fIII I.. (if' bo k, l i.s checked Tn'A)-
<br /> D. -Print the-chertrica:l namv of the hazardous.; substance..stored,-irr�,tbO tank and-the C".A.S* (Chemical
<br /> Abstra;:t Service iwugEr), if b,,o, i is NO checke,d .itt AT
<br /> III .. TANK CONSTRUCTION— MARK ONE ITEM ONLY IN BO`k-k -B, C & D
<br /> 1. -Check oni 'on€r item in TYPE. OF �YrTEM. TANK MATERIAL, INTEkIOR LINING and CORROSION'PROTE.CTION.
<br /> 2. if O'HER, print in the space prrvided:
<br /> IV. PIPING INFORMATION
<br /> -1. 'Circle A if above ground circle U if underground, and girdle:bath if ,applicab]e.
<br /> 2. If'UNKNOWN circle' .or if OTHER. print in space provide6
<br /> 3.. Indicate the LEAK-;t1ETECTION system(s) used to comply,with monitoring_ requirement far the piping :,
<br /> TANK LEAK DETECTION q
<br /> ': a:"' ,:'�- .. Agra.-:- - .:., •: . ..
<br /> h. Indicate the LEAK DETECTION system(s), used to comply with the mohitoring requirements for the tank.
<br /> VI. INFO1MTId K 0—TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. EST,MAf4D DA,TfCAST, USED - MOf�TH'YE:R (,lanuary, 1988 or 01/8R)
<br /> "2. E.ST1 A ED W45I1`ITY':of HA7AR.DOOS SUBSTANk'E remaining in the tank (in Gilfbn§).
<br /> 3. i`A5 TANK FILLED WITII INERT MATERIAL,? Check.-'Yes' or .'NO,
<br /> APPLICANT MUST 5,10'-AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The`.staTe underground storage'yt_ank identification number is compos+rd..of;the two digit county number, the three.
<br /> d get jurisdiction number, the six digit facility number and the- s.ix digit tank number. The county and
<br /> juioisdicti-on nutnbers'are.Pr0dete'rinined and can be obtained by calling the_State board "(916) 227-4303. The
<br /> facility number must bg.;ttTe'Salne as shown 'r. form "A The tank number-maybe assigned by the local agency,
<br /> however, this number mast be numerical and cannot contai•r) an alphabet. 1f.the local agency prefers the State
<br /> Board to assign the t;artk number. please leave it blank.
<br /> r T,4&,THE €ESPONSIBI+lTV THE LOCAL AGENCY.THAT-INSPECTS THE EACI ITV TO VERIFY THE ACCURACY OF THE
<br /> NFORMATION, THE LOOAL'AGEKY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL. AGENCY USE ONLY" INFORMATION BOX
<br /> FOR FORWARDING ONE FORM""A" AND ASSOCIATED FORK "B"(s) TO THE FOLLOWING ADDRESS.
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