COMPLIANCE INFO_1996-2003 - Laserfiche WebLink

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INSTRUCTIONS FOP COMPLETING PPM ''B'' GENERA! INSTRUCTIONS: 1. One FORM B" shallbe completed for each tank for all NEW PERMITS, PERMIT CFIANGES. REMOVALS and/or, any other TANK INFORMATION CHA=FE E 2. This form should be completed by either the PERMIT APPLICANT err- the LOCAL AGENCY UNDERGROUND TANK INSPECTOR, 3. Please type or print ,ear y all requested rr at ion. 4. Use a hard point writing instrument, you are making 3 copies, TOP OF FPM: 'MARK ONLY ONE ITEM" z. Mark a � � t} r.Y �' �El�°" �� best t d'sr }es the 'tsSrrthec}"r is btCricompleted, .a. Indicatethe DBA or a.... : t.r name where the tank is Irl,°. iled Im TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. indicate owners tank 1D # _ It there is a tank number that is aSfCEr i "x owner to identify the tank extS;i'�9i. B. indicate the rare 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 10,000etc.) I , TANK CONTENTS . A, 1. IF MOTOR VEHICLE FUEL, check box 1 and complete e i teas B & C, 2. if not MOTOR VEHICLE FUEL. check ti's appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the t MOTOR V ii �: (if tr`x a is checked in tib D Print nt t hey chemical name of the hazardous Erg's 'n ce stored i the tank and the .A `�_4' (Chemical f_`r t;r�ica L'C Abstract Service number). if box 1 is NOT checked in A. IIIe TANK CONSTRUCTION n MARK ONE ITEM ONLY IN BOX A, B, C & .t. Check only one item it TYPE OF SYSTEM. TANK MATERIAL, INTERIOR L 1NING and CORROSION PROTECTION. T if , print in the space provided, IV. PIPING INFORMATION CircleAif above wwound cycle underground,' circle wle. both if applicable, K 13 t OTHER. print provided 3 indicate the LEAK DETECTION system(s) used d to comply with the monitoring requirement for the piping, V. TANK LEAK DETECTION 1. indicate the LEAK DETECTION a . ., usedto comply with the monitoring ?ECU`r£`E"``s for the he t.iirlk: I. INFORMATION 014 TASK PERMANENTLY CLOSED IN PLACE �- USED Gln; rNTH/YEAR (January, 1988 or 01/88) , ESTIMATED ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remail ng in the tank (in Gallons), , 3. WAS P,Ny FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO' APPLICANT MUST SIN AND DATE THE PRM AS INDICATED. INSTRUCTION FOR THE LOCAL. AGENCIES The state underground storage tank tif i{ e or number is composed o .1� two digit county rhdr °rthe t?'{rfw'w digit jurisdiction number, the `,7x ; ._it; facility number and t. six digit tank number. The county and jurisdiction ion ntur;.ber s are predetermined s:i tied X n can be obtained in by calling the Striate Board (916) 227-4303 The facility number must be the sameas shown n form "A". The tank number may be assigned by the local agency, however, this number must. be numerical t and cannot _orf. an alphabet. If the local agency prefers the StateBoars to assign the tarok number , Please 3 '�(t blank. ark. ri L. 1 r,�4 C, IT IS TETE RESPONSIBILITY OF TEE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. TETE L&CAL AGENCY IS RESPONSIBLE FOR TETE COMPLETION GE TETE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR'FORWDING ONE FORM "A„ AND ASSOCIATED FORM 'B"(s) TO TETE FOLLOWING ADDRESS.