COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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tN1;FRUC110NS FOR COMPIZ11NO PORM"B" GENERAL IN,0'RU(711ON& 1, One DORM"B"shall be completed for each tank for all NEW PE.RM1715,PERMIT CHANGES, REMOVALS and/or any otherTANK INFORMATION CHANGE 2, This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3, Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP 017 FORM: *MARK ONLY ONE 17112W 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 installed. 1. TANK DOSCRIFFION-CX)MPILVIE ALL 171EMS-IF UNKNOWN-SO SPMFy 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 COMM-NIS A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. 2. If not MOTOR VEHICLE' FUEL,check the appropriate box in section A and complete items B& D. 13, Check the appropriate box. C. Check the type of MOTOR VEHICLE.FUEL(if box I is checked in A). , D. Print the chemical name of the hazardous substance stored in the tank and the C,A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. Ill. TANK CON451RUCTION-MARK ONE MIM ONLY IN BOX A,B,C&D 1. Check only one item in`I`YPE OF SYSTEM,"TANK MA'IERIAL, INFERIOR LINING and CORROSION PROTF(71`10N, 2. If OTIIER,print in the space provided. IV, PIPING INFORMATION 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 DEFECTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK 1>Ur1X711ON 1. Indicate the LEAK DE-1141CTiON system(s) used to comply with the monitoring requirements for the tank. VT. INFORMN11ON ON"TANK PERMANIW17LY(3A)SED IN PLACE, 1. ESTIMATED DATE i,,AsT USED-MONTII/YT- R(January, 1.988 or 01/88). 1 E-5.11MAT1.1)QUANl I rl'Y of IIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INI-1a MSFERIAL? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE 11111 FORM AS INDI(WIT-D. INSTRUCtION FORTU11.LOCA1.AGENC317-S 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. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (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. rr IS1711E RESPONSIB11XI'Y OF 111E IOCAL AGFNCY 11INFINSPECI'S TTIF FAC UT-IYTO VERJI,-f 1111i ACCURACY OFTTIE INFORMATION. 11111 LOCA1,AGENCY IS RE-SPONSIBLF FOR'17113 COMP1.11111ON OF 111E *LO(AL AGENCY USE ONLY*INFORMXIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM "B"(s)1`0-11111,FOLLOWING,ADDRESS. STAIE OF CALIFORNIA STIVIE W)VIE.R RESOURCE S CONTROL 130ARD C/O&W.114 E.P.S. DATA PROCESSING CENTER P.O.13OX 527 PARAMOUNT',CA 90723