Laserfiche WebLink
INSI'RUC:11ONS FOR CCIMPIXI ING FORM "B* <br />GENERAL INSTRUCJION& <br />1. One I{ORai1 "B" shall be completed for each tank for all NEW PERM17IN, PERMIT CIIANGES, REMOVAI: S and/or any <br />other TANK INFORMATION C.IIANGLF,. <br />2. This form should be completed by either the PERMTI' APPLICANT' or the LOCAL AGENCY UNDERGROUND 'IAVK <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 1T'FM' <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 DPSCRI1-`110N - COMPLIRM All, ITEMS - 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. 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 (6x. 1987). <br />D. Indicate the tank capacity in gallons (ex. 2.5,000 or 10,W0 etc.). <br />H. TANK CONTENI!S <br />A. 1.. If MOTOR VEHIC11" FUEL,, check box 1 and complete items B & C. <br />2. If not. MOTOR VEHICLE FULL, check the appropriate box in section A and complete items B & I). <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE Fi.7L'L (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 CONSI'RU(:110N - MARK ONiz rt'F.M ONLY IN BOX A, B, C & I) <br />1. Check only one item in 'TYPE OF SYSTEM, "TANK MATERIAL, INTERIOR LINING; and CORROSION PRO'I'I:CI'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 />3. indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK D.I3q`UC'ITON <br />1. Indicate the LEAK DI:'IFMON system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON "TANK PERMAN::NI1,Y CLOSED IN PLACE <br />1. ESTIMA'I1:D DATE I.AS1' USED - MON] :'LI/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of IIA/ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK Ill LLED WITIT INIiRT MA'IT.RIAL? Check 'Yes' or 'NO'. <br />APPI1CANr MUsr SIGN AND DAT]? 11 -IE FORM AS INDICATED. <br />INSTRUCTION FOR THE 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)739-2421. The facility number must be the same as shown id 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 111E RESPONSI:BTIJrY OF 111E LOCAL AGENCY TIIA'I' INSPECI S '1111? FAC7IM TO VERIFY 1111E <br />ACCURACY OF 1'1113 INFORMATION. TIIE I.,OC:AL AGENCY IS RESPONSIBLE FOR THI? COMPtHI10N 0I711IE <br />*LOCAL AGENCY USE ONLY" INFORMA11ON BOX AND FOR FORWARDING ONE FORM "A" AND AS,SOCINII?D <br />FORM "B"(s)1Y) '11IE FOLLOWING ADDRESS. <br />SCAIE Oil CALIFORNIA <br />'aI-A 1; WA113R, IIT:iSOURCFS CONTROL W?ART):, <br />CAC S.W.€3,f.: P.:S, <br />DATA PROCESSING (MIV113R <br />P.O. BOX 527 <br />PA OUNI', CA <br />