COMPLIANCE INFO_1987-1995 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLYFnN6 FORM'Ir GENERAL INS`IRUCI'ION,%- L One FOWM"13'shall be completed for each tank- for all NEW PERM1717S,PF.,Rmn,CHANG11,S, REMOVALS and/or any other TANK INFORM)VIION CTIANGE. 2. This form should be completed by either the PERMIT APPI,ICANI'or the LOCAL AGENCY UNDERGROUND TANK INSPW: YOR. 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 rllW* 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. I. TANK DI!SCRIYIION--COMPLUIV All.r1liMS-IF UNKNOWN-SO STECIFY A, Indicate owners tank 11) # -If thcre is a tank numbcr that is used by the owner to identify the tank (ex. AB70789), 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,"etc..). H. TANK CON17ENFS A. 1. If MOTOR VIqIlCLE FUEL, check box I and complete items B& C. 2. If not MOTOR VE"HIC1,13, FUEL,check the appropriate box in section A and complete items B& 1). B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). 1). Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Scrvire number), if box I is NOT checked in A. III. TANK COWIRUC110N-MARK ONE rnim ONLY IN BOX A,B,C&D L Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTI,,RIOR LINING and CORROSION PROTE-'C`rl0N. 2. If OTHER, print in the space provided. IV. PIPING INFORMN11ON 1, Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHE R,print in space provided. 3. Indicate the LEAK DMEPION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DRI13C11ON 1. Indicate the LEAK DETEcrioN system(s) used to comply with the monitoring requirements for the tank. VI. INFORMA11ON ON TANK PERMANEIV11,Y CLOSED IN PLACE 1. ESIIMATED DATE LAST'USED-MON11111YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANITrY of HAZARDOUS SUBSTANCE rema'ning in the tank(in Gallons). 3. WAS TANK FILLE,l)WYFII INERT MA'lrRIAI.,? Check'Yes'or'NO'. Appticwr MUST'SIGN AND DA71[71 111E FORM AS INDI(WI'ED. INSTRUCTION POR 111E LOCAL AGENCII—IS Ile 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. 'rhe facility number must be the same as shown in form "A". 'rhe 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 IS THE RESPONS'1131111Y 0171111.41'LOCAL AGENCY T1IK.I'INSPI?r1'S ITIE FACILrrY 1*0 VERIJ-1Y 17111 ACCURACY OF MIR INFORMATION. 11IF LOCAL AGENCY IS RESPONSIBLE FOR 1111i COMP11,711ON OF17113, 1"AL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCINIED FORM'B'(s)'110 111E FOLLOWING ADDRESS. 5VVrE OF CALIFORNIA STAIM WAIIIR RII;SOURCILS CONI ROL BOARD C/O&W.F-E.P.S. I I I " - f I I .. J : 4 DATA PROCESSING CMNTER P.O.BOX 527 PARAMOUNI',CA 90713