|
INSTRUCTIONS FOR COMPLETTNG FORM "B"
<br /> GENERAL .-INSTRUCTIONS:
<br /> 4�0 e F-`1' "B" �hail 1,e cn, f:)r each tari� for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any
<br /> Tic T-1
<br /> Othor TANK INFORMATION CHANGE
<br /> Th I f r-- �hould be ,oripiet-! ir,, either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> .INSPECTOR.
<br /> . I 'I eo
<br /> 3 Please t,-vnre or print � r11v 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 /> I 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 nami.., where the tank i� installed.
<br /> 1 . TANK DESCRIPT1ON '- COMPLETE ALL ITEMS - IF UNKNOWN '. SO' SPECIFY
<br /> T!,1.11�,_�jj,,, C�W. -,I,.S T!) -o i�, a nWnbe-r thrat is used by the owner to identify the tank
<br /> A If
<br /> (ex,
<br /> B Irdicate the�name- of' the companY that manufactured the tank (ex. ACME TANK MFG),
<br /> C. lrdicati� the year the tank wav� instulled (e.x. 19871
<br /> T
<br /> inrlicate the tank. capa(: ity in q?1lons tex. 25,000 or 10,000 etc.)
<br /> II. TANK CONTENTS
<br /> A, 1. IF MOTOR VEHIC! E FUEL, check box I and comple.te items B & C,
<br /> ItT(`
<br /> 2. if not M07 OR VL I 'I j- f jjjF1' , �heck the appropriatp box ill section A and complete items B & D,
<br /> B Chec� thi� apqproprlalf� Lhox.
<br /> C. 6ock the type of -W)JOR VIHICLE r(JEL (if' box I is checked in A).
<br /> D. Pri.nt the chemical, name of the hazardous substance stored in the tank and the C.A.S* (Chemical
<br /> Abstract '�'(,rvice numbor ). if bl-,�, I is N01 checked ill A.
<br /> III. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. Check or,!,, one jjeTq, jn'T1y'['j'- 'IF --1 1ANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION,
<br /> �)T[M
<br /> HIR. print -in the space [)-)vided.
<br /> if OT
<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 DE'ECTION systerri(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s) used to comply with'the monitoring requirements for the tank.
<br /> VI'. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1 ESTIMATD DATE LAST USED - MON'll'YEAR (January. 1988 br G1/88)
<br /> 2. ESTIMATED 00ANTITIV of HA 7 At,DOUS SUB�,TANCE remaining in the tank 06 Gallons),
<br /> 4�
<br /> 3. WAS TANK FILLED W111i INERi MA*T[.*.RIAL? Check 'Yes' or 'NO'
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number fs composed of the two digit county number, the three.
<br /> di git j urisdiction number, the six digit facility number and the six digit tank number. The county and
<br /> jurisdiction numbers are. predetermined and can be obtained by calling the State Board (916) 227-4303. 'The -
<br /> facility number must be the same as shown in form "A". The tank number.may be assigned by the local agency,
<br /> however, this number must be, numerical and cannot cont�in an alphabet. If the local, agency prefers the State
<br /> Board to assign the tank number,, please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF T-H1 LOCAL AGENCY T14AT INSPECTS THE F40ILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM *A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.
<br />
|