COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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INSIRUCIIONS FOR COMPLLTIING FORM"B" CrENEMAL INSTRUCTIONS: I, One FORM"B"shall be completed for each tank for all NEW PERMI'll'S,PERmrr aIANGES, REMOVALS and/or any other TANK INFORMA711ON CHANGE 2. This form should be completed by either the PERmn'APPLICANY or the LOCAL AGENCY UNDERGROUND`TANK INSPEC11ORL 3. Please type or print clearly all requested inform6tiba. 4, Use a hard point writing instrument, you are making 3 copies. TOP OF17ORM: *MARK ONLY 0N13.rFPM* L 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 DFISCRIP17ON-COMPLITIM All.r11:3MS-IF UNKNOWN-So SPF(31?Y A. Indicate owners tank I)#-If there is a tank number 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). 1). Indicate the tank capacity in gallons (ex.25,000 or 10,00(1 etc,). 11. TANK CONI1WIN A. 1,If MOTOR VFIIICLE FIJEi,,check box 1. and complete items B & C. 2. If not MOTOR VEIIICIT.' FUEL,check the appropriate box in section A and complete items B& D. B. Check the appropriate box. C, Check the type of MOTOR VFI ITCLE' FUI:.,,L(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. 11.1. TANK CONSTRUCLION-MARK ONE rmM ONLY Ill BOX A,B,C&1) 1. Check only one item inl IYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTFC11ON. 2. If 011lfiR,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 OT1113A,print in space provided. 1 Indicate the LEAK DETEC71ON system(s) used to comply with the monitoring requirement for the piping. V. TANK IMAK DHI1rI1ON 1. Indicate the 11"K D1:14TECf`ION system(s)used to comply with the monitoring requirements for the tank. V1. INFORMATION ON TANK PERMANUNI'LY CLOSEI)IN PLACE L ES11MATED DATE LAST USED- MON711I/YEAR (January, 1988 or 01/88), 2. ESTIMATED QUANTITY of HAZARI)CAJS SUBSTANCE' remaining in the tank(in Gallons), 3. WAS TANK FILI.1�1I)WIT11 INFR7. MATERIAL? Check 'Yes'or'NO'. APPLICANT MUST SIGN AND DATI 'IIIE FORM AS INDIC)VIVI). INSTRUCTION MR TIM LOCAL AGENCIES The state underground storage tank identificatiod 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 sante 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 ISTIIE RESPONSIBILITY OF TIIE.LOCAL AGENCY ITIAT INSPIX,'I',S'I1IE FACIIX1'YTO VERWY 11111 AC('URA(,'YOI?'nil?INIX)RM)VIION. TIIE LOCAL AGENCY IS RESPONSIBIX FOR TILE;COMPLInION OF TTIE "LOCAL AGENCY USE ONLY*INFORMNIION BOX AND FOR FORWARDING ONE FORM'X AND AS,"3NIIED 17ORM'B'(s)-1`0 TITE FOLLOWING ADDRESS. 917A173 OF CALIFORNIA SI'NFF WN11A RESOURCES CONTROL BOARD C/o S.Wnl—rps. DA'T'A PROCI.NSING CFN11,1R P.O.BOX 527 PARAMOUNT,CA 90723