Laserfiche WebLink
INSTRUCTIONS FOR COMPIX?IING 11"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PFRA4r1N PERMIT CHANGES, RF..MOVAIS and/or any <br /> other TANK INFORMN11ON CHANGE. <br /> 2. This form should be completed by either the PERMIT APPUCANT or the I AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 1 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 rl'EM" <br /> t 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 /> I. TANK DESCRIP11ON-COMPI=.ALL T'IT-WS-IIF 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.AB70789). <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 /> 1). Indicate the tank capacity in gallons(ex.25,(-W or 10,000 etc.). <br /> H. TANK CONT FWI',S <br /> A. 1. If MOTOR VI3111CLE FURL,check box I 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,.,N.S,#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSI'RUCTION-MARK ONE 1`11W ONLY IN BOX A,K C&D <br /> 1. Check only one item in TYPE Of, SYSTEM,'I'ANKMA'I'ERIAI.,, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHET-1,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 011IFF,print in space provided. <br /> 3. Indicate the LEAK D system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANIC-LEAK.DET1z)C17ION <br /> 1. Indicate the LEAK DM.'ECI]ON system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON TANK PERMANENTIM CI)OSED IN PLACE <br /> 1. ESI`IMATED DNI`F,LAST USED-MON`ITI/YM. R(January, 1988 or 01/88). <br /> 1 ESTIMATED QUANTITY of HAZARDOUS 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 1111H,FORM AS INDICNIED. <br /> INSTRUCITON FOR'11 ILI LOCAL AGENCIF-S <br /> 'Die 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 /> rr IS THE RESPONS1131111'Y OF THE U)CAL AGENCY THAI'INSPECI'S'11113 FACILITYTO VERH7Y`nIH <br /> ACCURAC`Y OF UIF INFORMATION. 111E L(XAI,AGENCY IS RESPONSIBLE FOR IIIE COMPIEHON OF 17111 <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM*A*AND ASSOCIATED <br /> FORM-B'(s)-M 711E FOH.OWING ADDRESS. <br /> STALE OF CALIFORNIA. <br /> STATE WA717ER RF-SOURCES CONI'ROL BOARD <br /> C/o S.W.EF-P-S. <br /> DATA PRoctmaNG cT.Nnm <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />