|
1NS'I7tUC711ON5 17OR CG: MPIZIING FORM Ir
<br /> GENERAL INSIRUCAONS:
<br /> 1. One.FORM "B"shall be completed for each fank for all NEW PFAWl'S, PERmn,CIIANGEN, RFMOVAI-Sanu1/(:,,r any
<br /> other'TANK IN'17ORMA11ON CHANG17-
<br /> 2. This form should be completed by either thePERM1717 APPI.ICANIC,;r the LOCAL A(;I.N(--f UNDERGROUND TANK
<br /> INSPECIYJR-
<br /> 3. Please type or print clearly all requested ir;Fomation.
<br /> 4. Use a hard point writing instrument,you.v re making 3 copies.
<br /> TOP OF FORM:`MARK ONLY ONE riEw
<br /> 1. Mark an (X)in the box next to the item mrt')cst describes the reason the form is being complete(.
<br /> 2. Indicate the DBA or Facility name where k'be !aank is installed.
<br /> I. 'TANK DIISCRIFILION-(Ompurn.7.Au rnwS, X i..NKNOWN-SO 3i'm—ley
<br /> A., Indicate owners tank 11.) #-If there is V :),umber that is ustd '>y the owner to identify the tank (cx.A1370781)),
<br /> B. Indicate the name of the company that 3,, "urccl the tank(, 11 IIETANK M17CO,
<br /> C;. Indicate the yr.,tr tlic iank was installed f,,.: 1.
<br /> D. Indicate the latilk capacity in gallons (ex, i0,00()ctc.)
<br /> 11, TANK CONIV:NIN
<br /> A_ 1.If MO]I OR Vl;lllCl,,E FUTE.L,check N,)x i and complete items 13 & C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B R 1).
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VERIELL.FUL.1,(if box 1 is checked in A),
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A,S,#. (Chemical Abstract Service
<br /> number), if box I is N(YT checked in A.
<br /> 111. TANK WN917tU(717ON-MARK ONE ITEM ONLY IN BOX A,11,C&1)
<br /> 1. Check only one item in'I-YPE OFSYSTEM,'TANK NIXI'ERJAL, INTERIOR LINING and CORROSION PROTI`ICXTON
<br /> 2. If OTIIER,print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1. CircleA.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 DTT. ECTlON system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK D11r][W711ON
<br /> 1. Indicate the LEAK DI!FECFION system(s) used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMN17ON ON TANK PY7.RMANFN`I1,Y CI AXSE*1)IN PLACE
<br /> 1. ESTIMATED DATE 1AS`1'USED-MION'1111YEAR(January, 1988 or 01/88).
<br /> 2. ESTIMNFFI)QUAWITY of TIA7ARDOUS SUBSTANCE' remaining in the tank(in Gallons).
<br /> 7
<br /> 1 WAS TANK FILLED WrIll INERT MA'1'1-'.RIAI.'? Check'Yes'or'NO'.
<br /> APPLICANT'MU,";I'SIGN AND DA'11i'llIE]FORM AS INDICAITID.
<br /> IN,KFRXJC11ON R)R'nIE LOCAL AGFN0M
<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 numbers 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 /> 0
<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 /> rl'IS ITIE RESPONS11311.17fY 0171TIE LOCAL AG13N(,Y1Tvvr iNsPurms'niv mcunYro VERITY THE
<br /> ACCURA('Y OF 1111i INIX)RMA'110N. TIIE LOCAL AGENCY IS RF-SPONSIBLF FOR171F COMPLETITON OF'IIIE
<br /> *I,O(:AL AGENCY USE ONLY*INFOR?i"11ON BOX AND FOR FORWARDING ONE FORM W AND ASSOCIN171)
<br /> FORM-B-(s)T0'111F FOLLOWING,ADDRE�--!
<br /> STNFE.OF CALWORNIA
<br /> S-17NIE WJV17ER RF-AX)URCF-S CONTROL BOARD
<br /> C/o S.WJLRP.&
<br /> DATA PROCESSING C-1:'WlFEzR
<br /> P.O.BOX 577
<br /> PARAMOUNT,CA 90M
<br /> 0
<br />
|