COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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• s #: rr ^'' ,. ,. � � - .. .-_'. 11,ds:•�`y of °c.. INS-FRUC;IIONS FOR C OMPLITI.7NG FORM'Ir GENERAL INS-17RU01ONS: L One. FORM "B"shall be completed for each tank for all NEW PFR; 1'Is,P1?12Mf (31AR(;V...S, REMOVAUS t�n�1;3r ani other TANK INPORMA17ON C:TIANGR 2. 'Phis form should be completed by either the PERMIT APPLIC:ANI`or the LOCAL AGV,NCY UNDERGROUND'PANIC INSPIR 1'OR. ' 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,ytlu xte m4king 3 copies. , 'IOP OF FORM:"MARK ONLY ONE 11711:'N" I. Mark an.(X) in the box next to the item that best describes the ,mason the form is being;completed. 2. Indicate the DAA'or p'acility name where the tank is installed. L 'TANK.DESC:RWFION-COMPI:,I 1'E ALIT.1`17?MS-117 UNKNOWN-SC)S11WIFY A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.AB70"789), B. Indicate the name of the company that manufactured the tank(ex. ACME'I'ANK N117G.). C. Indicate the year the tank was installed(ex. 1987). I). Indicate the tank capacity in gallons(ez. 25,(00 or 10,000 etc.). 11, 'LANK C'ONIT31VI'S .A. 1. If MOTOR VEHICLE FUI.°L,check box I and complete items B & C. 2_If.not MOT"ORWE'RICLE L UI3h,check the appropriate box in section A and complete items B & D? B. Check the appropriate box. C. Check the type of 11�IO7'OR 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 I is NOT checked in A. III. TANK C:ONSTRUCIION-MARK ONE 17ITF,M ONLY IN BOX.A,B,C:& D 1. Check only one item in'I`YI'E OF SYS1'I-. `FANK M2`1I� I,AI, 1N71HRIOR LINING and CORROSION FROTF?("hEC�t�. 2. If O'I7IER,print in the space provided. IV. PIPING INFtORMN11ON r 1. Circle A if above ground; circle U if underground; and circle bath if applicable. 2. If.UNKNOWN, circle; or if OTLIER,paint in space provided, 3. Indicate the LEAK DP7'F,C`I1ON system(s) used to comply with the monitoring requirement for the piping. V. 'TANK LEAK DI3IIK'nON 1. Indicate the LEAK DETT,.C':17I0NT system(s) used to comply with the monitoring requirements for the tank. Vl. INFORMATION ON TANK PERMANFIVI7 Y C1,11.)SID IN PLACE 1. FSTIMA'1171:D DA'I73 LAST USED-MONT]I/PEAR(.January, 1.988 or 07/88), 2. ESTIMA'WD QUANTI'1Y of 1IA/ARDOUS SUBSI'ANC 11' remaining in the tank (in Gallons), 1 WAS TANK FILLED WII7I Check'Yes'or'NO'. APPLICANT MUST SIGN AND DiVIV 111E FORM AS INDICX11i INS1'RucnON FOR 111E IACAL AC31914013S 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 tic the same as shown in ft-n-m "A". The l `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, ITIS 1I1E R.ESPONWILTI'Y OF 111E LOCAs.AGI:iN(Y'IIIAT INSI I: 'I's' ,nlF FAC,"II..11"Y TO VITRIFY 71IT1 ACCURACY OF 111E INFORMA770N. '1111:1 r C)CA1,AGENCY. IS RKSPONSIBIM FOR 711E COMPIH170N 01117111 *LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR R) WARDINCa ONV'DORM"A"AND AW)CIN11D FORM"B'(s)TO 771E FOLLOWING ADDRENS, SPATE 017 CALIFORNIA ;a17A:IV W)VITA R13SO1.140N CONTROL BOARD Illi°I PRf ti 1NMNG CSI Fa[I V'R P.O.BOX 527 PARAMOUNI',CA r 3