Laserfiche WebLink
N � <br /> INSTRUCTIONS FOR C'OMPLE'LING i"RM*B" <br /> GI:?NERAL INS['Rt K"c IONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMTI'S,PERMIT CIIANGI?S, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE? <br /> 2. This form should be completed by either the PERMIT APPLICANT or the IOCAL AGENCY 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 rIEM" <br /> 1. 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 name where the tank is installed. <br /> L TANK DESCRIPTION-COMPLEI E ALL r1EMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank (ex.A1370.789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> R. TANK CAN'I1W15 <br /> A. 1.If Mt7'I'OR VEHICLE FUEL,check box 1 and complete items B&C. <br /> 2.If not MOTOR.VEHICLE 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 VEHICLE FUEL(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 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MA'T'ERIAL.,INTERIOR LINING and CORROSION PROTECTION. <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 /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEFECTION <br /> 1. Indicate the LEAK DEFECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANI3NILY CLOSED IN PLACE <br /> 1. ESTIMATED DATE IASL'USED-MONIII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of I-IAl.ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WITH INERT MATERIAL.;? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE'11111 FORM AS INDICATED. <br /> INSTRUCTION FOR TIIE LOCAL AGENCIES <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)734-2421. 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 /> rr IS THE RESPONSIBILITY OF TIII1 LOCAL AGENCY THAT INSPEC S 777E FACILITY TO VERIFY TIIE <br /> ACCURACY OF TIIE INFORMATION. THE LOCAL AGENCY IS RE.STONSIBLE FOR TILE COMPLETION OF THE <br /> 'LOCM.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOCIATED <br /> FORM-B-(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAID WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E E.P.S. <br /> DATA PROCESSING CI PIPER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />