Laserfiche WebLink
7 <br />V�77 T <br />1?N <br />ilsisrizucnolsis FOR COMPIJUING FORM *Ir <br />GENERAL. INSIRUCIIONS: <br />1. One FOKM "B" shall be completed for each tank for all NEW PERM1717S, PERMIT` CITANG13S, REMOVALS and/or any <br />other TANK IN17ORMNIION 01ANGIL? <br />2. This form should be completed by either the PERmrr APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br />INSPWI7OR- <br />3. Please type or print clearly all requested information. <br />4. Use a hard point writing instrument, you are making 3 copies. <br />'17OP OF FORM: *MARK ONLY ONE rll!AC <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 />1. TANK DESCRIP711ON - WMPLIn'F, ALL rWMS - IF UNKNOWN - SO SPFCIFY, <br />A. Indicate owners tank 11.) # - If there is a tank number that is used by the owner to identify the tank (ex. A1370789). <br />B, Indicate the name of the company that manufactured the tank (ex. ACME TANK MF -G,). <br />C. Indicate the year the tank was installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,()X) or 10A)0 etc.). <br />U. TANK CONnINI'S <br />A. 1. If MO'I'OR VEIIICLF FUET, check box I and complete items 13 & 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 siibstance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br />number), if box 1 is NOT' checked in A. <br />HI. TANK CON,';FRU(711ON - MARK ONE rITW ONLY IN BOX A, 11, C & D <br />1. Check only one item in TYPE OF SY51'EM,TANK MATERIAL, WI`1:41'RIOR LINING and CORROSION PRO'ITC717ION. <br />2. If 011IER, print in the space provided, <br />IV. PIPING IN17ORMXIION <br />L 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 131117ECTION <br />1. Indicate the LEAK DLMH.'FION system(s) used to comply with the monitoring requirements for the tank. <br />VI. IN[FORMA71ON ON TANK PERMANFNn.,Y (TOSIA) IN PLACE <br />1. E-S-11MATED DATE LAST USE .,,D - mowivyl-AR (January, 1988 or 01/88). <br />2. FSFIMA117D QUANrrry of TIA,7AW)OUS SUIWI'ANCE remaining in the tank (in Gallons). <br />1 WAS TANK FILLF*11) WFITI INERT' MATI.IRIAL? Check 'Yes' or 'NO'. <br />APPLICANI'MUST SIGN AND DA11111TH FORM AS INDI(WM;D. <br />INSTRUCTION FOR11TE LOCAL AGINCIF-S <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 />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 />171' IS TIJE RESPONS11311,171lY 017 T11 LOCAL AGFNCYTHAI' INSPM-17S 11113 FACILTITTO VERIFY 111B <br />ACCURACY OF 1111? INFORMA7.110N. 7nIE LOCAL AGENCY IS R0SPONSIBLE FOR 11LE COMPIT.-TION OF 7711E <br />'LOCAI, AGENCY USE ONLY* INFORMA11ON BOX AND MR FORWARDING ONE FORM "A" AND ASSOCIA11113 <br />FORM -B'(s) -170 `171111 FOLLOWING ADDRESS. <br />STAT F OF CALIFORNIA <br />S-17NITI W/VI7ER RESOURCES CONTROL BOARD, <br />C/O S.W.Er-.P.S. <br />DATA PROCESSING (1.71VER <br />P.O. BOX 527 <br />PARAMOUNT, CA 90M <br />