COMPLIANCE INFO_1989-1990 - Laserfiche WebLink

Home Browse Search

INSIRUCIIONS FOR COMPLITI'ING.FORM'B" GENERAL.INSTRUCTIONS: 1. One FORM "B"shall be completed for each tank for all NEW PERMI715,PERMIT C:IIANGE� REMOVAIS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANTor the LOCAL AGENCY I JNDERGROUNDTANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM:'MARK ONLY ONE MWI 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installid. . 1. TANK DFSC.RIPIION s COMP1 VIE?All,r112AS-IF UNKNOWN-SO SPF.,CIFY A. Indicate owners tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.A1370789). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). Il. TANK C'ONIMMI S A. 1. If MOTOR VEHICLE FULL,check box 1 and complete items B K C. 2. If not :MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). I). Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Scrvice number), if box 1.is NOT.checked in A. M. TANK CONSTRUCTION-MARK ONE rIEM ONLY IN BOX A,11,C&D 1. Check only one item in TYPE OF SYSTEM,"TANK MATERIAL,, INTERIOR LINING and CORROSION PRO 'EC'I'TON. 2. If OTHER,print in the space provided. IV. PIPING INFORMA'I1ON 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER, print in space provided. 3. Indicate the LEAK DI-I13C'I1ON systems) used to comply with the monitoring requirement for the piping. V. 'TANK LEAK DL?'IECTION I. Indicate the LEAK DE n7,CTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMA71ON ON TANK PERMANLNII.Y CLOSM IN PLACE 1. ES'I7MA71 D DATE LAST USED-MONTII/YEAR(January, 1.988 or 01/88). 2. ESTIMATED QUA.tiI'I`TY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WTI11 INERT MATERIAL;? Check 'Yes' or'^i O'. APPIdCANT MUST SIGN AND DATIi TtlE,FORM AS INDWA 1117. tNSTRUCTION POR 111E LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number,the six digit facility number and the six digit tank number. 1'he county and jurisdiction numbers are predetermined and can be obtained by calling the State I.3oard (916)739-2421. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency: however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. IT IS TAE RFSPONSHIH.X..IY OF THE I OC'AI.AGENCY'THAT INSPECIN 11L13 PAC IIII'Y 1'O VERIFY THE ACCURACY 01711I1?INFORMATION. 113E LCXW,AGENCY IS RESPONSIBLE FOR 11Hi COMPLE'1.1ON OF111E, 'IMAM AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOC7AI1?d) FORM-W(s)TO 11{E FOLIAWtNG ADDRESS. STATE OF CAH ORNIA ST11IF..,WNIT"R RI?-SOURCES CONI'ROL BOARD C/O S.W np.S. DATA PROC.'I SING CINI1?R P.O.BOX 527 PARAMOUNI',CA 90723 - --..,. ... .ra. '1 _.. Y�a'2,a."1�� _ �:+.i�M"'t�'Y[�:.'��' �. a:�iM^'.'.. J►litx.` �,..w _ °�'.._.. :..._..-- --- ..�.,.,,�.__._. ..�:,: