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INSTRPCTIONS FOR COMPLETING FOF:M "B"
<br /> G-NERAL' INSTRUCT IONS:
<br /> 1 One f i)" '6 s is f 'i ch "ank for, a'1'1 NEW PERMITS. PERMIT CHANGES, REMOVALS and/or any
<br /> `Ltrc TANK INFORMATION CHANGE
<br /> Thr, f�)r-,i .ho I d to ,r^N i et .; r Lhc,r thkA- PERMIT AAP(.CI�ANT or the LOCAL AfGENC'Y-tN+iDERGROUND TANK°..
<br /> INSPECTOR
<br /> 3 Please tv.n�> or p.Nint clearly a.1 r-quested information.
<br /> 4 Us0� a hard point writking ing instrumen,t. .you are ma3 C tes.
<br /> _ ..
<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.bei.ng completed.
<br /> 2 Indicate the DBA or- Facility namE., where the tans; is installed.
<br /> I . TANK DESCRIPTION - COMPLETE AL.L' ITEMS IF UNKNOWN SO SP IFY
<br /> A In :a?., t w ;�, t a..'r.. Il. If t',,, o 'I s.a tan' number th4t r s used,by the owner to"ident i fy the tank
<br /> F In; ..et.e: the nam- of._the c..ompanv that manufactured the tank 0ex. ACME TANK MFG),,
<br /> IndicatD Indicate the tank caper i v in a?1 ioms (ex 25,000 or
<br /> e ti,e year-th ta,k War r:sted (ex,
<br /> o-i i . k94') 1(}.00iO etc.)
<br /> II TANK CONTENTS
<br /> A,' 1. IF MOTOR VEH1CLt FUEL, chedk box I and Complete items B1 C
<br /> .2. if not MOT{iR Vt_tiTt:.l E HAL check the appropriate box xn 5eetion A and. complete items B & D.
<br /> B (-,heck the appropriale box _
<br /> C flIkk the Py(e of MOTOR VI H I CI E III[A. (if box /, is chkked`.i n A)
<br /> D Print the chemical.name of the hazardous substance stared, in the taftk and the, C.A.'S:#. (Chemical
<br /> Abptract. ervice nuruber ;, if tia!x i is .ti)t checked in A.
<br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY :IN BOX A. :B, t & D
<br /> I. Check only rare item iii TYPIL.. OF cySTEM TANK MATERIAL, INTERIOR DINING and CORROSION PROTECTION.
<br /> C. If OiHtR. [)rint. in the space p,_.,vided.
<br /> IV. PIPING INFORMATION
<br /> 1. Circle A if .above ground circle U if underground, and circle kaotFi`,�fapP ,i cable. '
<br /> 2. If UNKNOWN circle or if OTHER, print in space provided .-
<br /> 3 Indicate the LEAK DETECTION system(s) used to. com>ly.w,ith, the. re€�irement for, the piping:.
<br /> V. TANK LEAK DETECTION
<br /> 1: Indicate the LEAK DETECTION system(s) used to comply with the.,mon�tc>^dig r`equ}rents fiar the tank.
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> I. ESTiMA,ED BATE LAST USED - M til H?YEAR (Januar, 1988 or 01/88,Y`
<br /> , � s
<br /> 2.. ESTIMATED 'OANiiTY of H�.ct�'?UUU� SUr'STA.NCE remaining in theltarifC (`in GeT1'orrs).
<br /> 3. WAS )AHK F T
<br /> iLLED FWI;H iNER" MA.TERIAL? Check 'Yes'' or.'NO' �. . . _
<br /> APPLICANT MUST SIGN AND DATE. THE FORM AS INDICATED. � ..
<br /> :INSTRUCTION FOR THE LOCAL AGENCIES The state underground, sto age.:tank identification number is co osetf-of the.`,.-twodigit County number; the three'
<br /> d i 9 i t ,Iuri sdi ct ion number, the si x d i g i t fac T 1.i ty number and the s4-digft•t��k hwhber w The county.,and
<br /> jurisdiction numbers are predetermined and can be obtained by' cal Ting"th ; to `°gv rd I916) 227-43fj3: Thee-
<br /> facility number must be the same as shown in form "A". The ;tank number day 1 a ;signed by the local agency:
<br /> however, this number must be numerical and cannot contain an alphabet' If .the loepl agency prefers 1hre Mate
<br /> Beard to assign the tank •nbriber. please leave it blank.
<br /> IT IS THE—RESPONSIBILITY 4F°THE LOCAL AGENCY THAT-INSPECTSTHE,FACILITY 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 /> ,, .;0,
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