Laserfiche WebLink
-.1;g' .s='---.—,,— -'-,"Z-";—"—,"---'--a—� <br /> IN,51'RUCLIONS FOR COMPI1-'17NG FORM"B" <br /> GENFRAT,INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PURMI'l-S,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGF- <br /> 2. This form should be completed by either the PERMIT APPLICANT or the I.00AL AGINCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:'MARK ONLY ONE M1M" <br /> 1. Mark an(X) in the box next to the item ;,hat best describes 6-.c ,ea on the form is being completed. <br /> 2. Indicate ttie DBA or Facility name where the tank is installed <br /> I. TANK DESCRIVIION-COMPLETE ALL 1T11M5 IF UNKNOWN—SO SPECIFY <br /> A. Indicate owner-,tank ID #-If there is a tank number that is 4scJ by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank{z-x.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (��x. 1987). <br /> 1). Indicate the tank capacity in gallons(ex -',000 or 10,000 etc.). <br /> H. TANK CONIENIS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2.If not MOTOR VFIIlCLE FUEL,check the appropriate box in section A.and complete items B&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEIIICLEFUI:IL(if box I is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK CON,1;I[1ZUC71'ION-MARK ONE Y117M ONLY IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL..;INTIT.'RIOR LINING and CORROSION PRo'rE(.-,I'ION. <br /> 2. If OTHER,print in the space provided. <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 /> 1 Indicate the LEAK DT,-I'E(.'IION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DumcnoN <br /> 1. Indicate the LEAK DI.,.-FLCI1.ON system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANIWILY CIDSED IN PLACIM <br /> 1. 01�11MATED DATE LAST USED-momnl[YEAR(January, 1988 or 01/88). <br /> 2. FSTIMATED QUANTITY of HA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTI'11 INERT MA'IERIAL?Check'Yes'or'NO'. <br /> APPLICANT musr SIGN AND DATE"ITIS FORM AS INDICA110, <br /> INSTRUCTION FORTIIE IX)CAL ACHIN(MiS <br /> The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction <br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction number,-,are predetermined and <br /> can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form "A". The <br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT IS T7111 RESPONSIBUXI'Y 017 TIIE IA)CAL AGENC-f TIJAT INSPIX"M'71111 FAC111TY'PO VERIrY111E <br /> ACCURACY OF 11113 INFO.RM)VIION. 77117 LOCAL AGENCY IS RENTONS113111 FOR'11113 COMPIVITON OF TIIE <br /> "IDCAL AGENCY USE ONLY"INFORMX11ON BOX AND FOR FORWARDING ONE FORM"A*AND ASSOCIN.11 1) <br /> FORM"13"(s)10 ITIE FOLLOWING ADDRESS. <br /> gffni OF CALIFORNIA <br /> 9.17XIV WAII.W RKSOURCIN CONTROL BOARD <br /> DATA PROCESSING(TWIllik <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />