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INSTRUCTIONS FOR COMPLETING F Orr"M "B"
<br /> ,.h GENE: -INSTRUCTIONS: N�. 71.
<br /> I` "Orle FORM "B" shell :, m,: r ' .),- each tank fpr all NEW-PERMIT$; PERMIT CHANGES. REMOVALS and/or any
<br /> ether TANK'.INFORMATION CHANGE
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<br /> T M i form chub td bo, ;>rnp i of dt.' . a t here the"PERMIT APPLICANT:t�: tti
<br /> � e COCAL' AGENCY UNDERGROUND TANK
<br /> '1`NSPECTOR".A r
<br /> 3 fro« or print clearly a'l requested information.
<br /> A Use a hard point writing insirumert, You are making 3 Copies.
<br /> f
<br /> TOFF FORM: 'MARK ONLY ONE ITEM,"
<br /> 3. I Mark an (X) in the•box next to the item that best describes the reason the form is being completed,
<br /> r.?
<br /> Indicate the DBA'-or ,Fac i 1 i t y,namo. wha:r the tank is i1t5t,#1 l eft
<br /> I.. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN SO SPECIFY
<br /> A. a;,> w sc>rs ta.`k ri. - If h; re., Is .a tani: numbtr ttatis, used by the owner to identify the tank
<br /> (ex. AB ( ;H97:
<br /> B indi at tr:tviame of_ the ec�mpiar?y that marrafactu^ed tie hank (rax. ACME_ TALK MFG)..
<br /> -xt; Tndi�a�r the -year ;hc tank, wasirstalled (ex.' 1981).
<br /> :.
<br /> D.
<br /> Indicate `he' lank capacity in gallons (ex 25.000 or 10.000 et-c }
<br /> II. TANK CONTENTS... .
<br /> A.. 1. I1= MOTOR VEHICI.E'`FIiEL,'r.heek box 1 an'd complete items B'&'_�.
<br /> 2, If riot MOTOR VCIiI'CI E FlUEt , c:hec:k tho appropriate box 4n'sect ion-A`and compiete�items B & D. ,
<br /> 13 Chick thr� aparopri"ale box
<br /> ','C. Check .hE. type'of XMfflR VE HI CL E I UE,1. (if' box- 1 is checked in A).
<br /> D Print the chemic,*'uawo of the hazardous substance stored.in the tank and the C.A.S* (Chemical
<br /> Abstract. Service number). if bo,, i is NOi checked in.A.
<br /> I II. TANK CONSTRUCTION ,:- MARK ONE .ITEM ONLY IN BOX k B�r. G '& D
<br /> 1. Check onl.v one-item i.n TYPE- OF ,YS7c:M TANK MATERIAL, 1NTER10R LINIPdG and CORROSION PROTECTION
<br /> 2. if OTHER, print in the spa(_e pr,rlvided.
<br /> IV. PIPING INFORMATION
<br /> 1. Cirche A 1f above.gropnd circle U if underground. anc[ d rde both if appl.icable. .
<br /> 2. If,:UNKNO'WN circle.::For if OTHER, print in space provided
<br /> 3. Indicate the LEAK DETECTION system(s) used to comply with.4he monitoring requirement for the piping.
<br /> V. TANK.LEAK.DET-ECTI6h
<br /> 1. " Indicate the. LEAK.,WTECTION system(s) used 1:0-comply with aW,monitotirig"requirements for'the tank.
<br /> YI "INFORMATION ON TANK PERMANENTLY CLOSED IN.PLACE.., r .
<br /> 1. ESTIMATED DATE LAST USED M0N i1/YE-AR (January. 1988 or 01/88)
<br /> 2. ESTIMATED QUANTIf-f'6f HAZARDOUS SUBSTANCE remaining in the" tank din Gallons).
<br /> . . ry
<br /> _,.,3. Lr'A� TANK FILLED_WITH iNER7 MATERIAL? Check 'Yes' or 'NQ'
<br /> APPLICANT MUST SIGN'AND DATE THE ,.FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> the state underground storage tank identification number is cocti�sed of. the two digit county number, the three.'
<br /> digit jurisdiction number;the six digit facility number, and-the.six digit tank number. The county and
<br /> jurtsjitction`numbers are:prkdetermined and can be obtained,by cal=ling: :State Board (916) 227.4303 The
<br /> facility number m t b?x-tfse same as shown in form "A The tank ut�ber may be,assigned by the local agency,
<br /> 'however, this num�er must be numerical and,cannot contain an alphabot,'Jf., rhe local agency prefers the State
<br /> Board to ass3gn- 004ank.n er.• please leaye it blank-.%i
<br /> IT IS THE 'RESPi SIBTLITY OF-TME-LOCAL AGENCY THAT,,,-INSPEOS THE FACTLI`f'Y TO VERIFY THEY=ACCURACY"-OF THE K
<br /> INFORMATION. THE -LOCAL` ENCY: IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> IND FOR FORWARDING ONE'FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.
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