COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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T7�-4 llw"'-Y�:7 INSTRUCTIONS FOR COMPLFIING,FORM'B" GENERAL IN917RUCIIONS' 1. One FORM"B"shall be completed for each tank for all NEW PERM17.0i,PERMIT CITANCAN, RFMIOVAI-Sandiorany other TANK INFORMKITON CI IANGF- 2. This form should be completed by either the PERMIT APPIJCA.NI'or the LOCAL AGENCY UNDERG)ROUND TANK INSPW: lrOR- 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. 11OP OF FORM:'MARK ONLY ONE r11M L Mark an (X) in the box next to the item that!-.est describes the reason tile form is being completed. 2. Indicate the DBA or Facility name where the lank is installed. I. TANK DF-SCRIVIION-COMPTHI'Ll All.17174AVS-[IT UNKNOWN-SO SPfXM?'Y A. Indicate owners tank ID If there is a tank number that is used by the owner to identify the tank fex.Af.370789). B. Indicate the name of the company that mintifactured the tank C. Indicate the year the tank was installed (ex, 1987). DIndicate the tank capacity in gallons(ex. 25,000 or 10,000 ctc.). 11 TANK CONT'HNn' A. t If MOTOR Vf3]I ICLE,FUEL,check box I and complete items 13&C 2. If not NfO'.I'OR VEHICLE 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), 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 CONSIMUCTION-MARK ONE 1111M ONLY IN BOX A,B,C&D L Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. 2. If OITIER,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 OILIER,HER.print in space provided, 3. Indicate the LEAK Dii-FEC711ON system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETEC'17ON 1, Indicate the LEAK DIT-17ECTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESIIMATED DATE IAS]'ILJSII)-MONI'll/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANIITY of IIAZARF)OUS SUBST'ANC'E remaining in the tank(in Gallons). 3. WAS TANK FILLED WFIJI INERT MiVIT,R[AL?Check 'Yes'or'NO'. APPLICANT'MUST'SIGN AN13 DA113.11111 FORM AS INDICNfEIX INSTRUCTION FOR IIIE LOCAL AGENCIES 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. Ilie 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 shoxvm 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. rF IS THE RP—SPONSIBUX"OFTIM LOCAL AGENCY'I'IIKI'INSPM:l*S'17[ILI FACILITY 11.)VERIFY11TE ACCURACY OF THE INFORMATION. THE DDCAL AGENCY IS RF-SPONSIB11-FOR 111E COMPLIT11ON OF IIIE *LOCAL AGE3NICY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM V AND ASSOCWI'ED FORM-W(s)W THE FOIJ,0WING ADDRF-%. SPATE OF CAI.1PORNIA STATE WA17FR RFSOURCES CON1`ROI.BOARD CIO S.W.F-F-PS. DATA PROCESSING CEWIMR P.O.BOX 527 PARAMOUNT,CA 90M