COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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INNYRUMIONS FOR CX)MPLVIING FORM*B* GENERAL INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERWIN,PERMIT CHANGIN, RF MOVAI-S and,or any other TANK INFORMA711ON CIIANGF- 2. This form should be completed by either the PERMIT APP11CANVor the LOCAL AGENCY UNDERGROUND"TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you ire making 3 copies. Oil FORM:'MARK ONLY ONE TIIN" 1. Mark an (X) in the box next to the item tha.,!vst describes thereason the form is being completed. 2. Indicate the D13A or Facility name where the tank is installed. I. TANK DESCRIV1710N-COMPLE'113 ALL rIT-WS-IF UNKNOWN-SO SPECIFY A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(cv.A1370789). B. Indicate the name of the company that mifnulactured the tank(ex. �,c,',""FTANK MFG.). C. Indicate the year the tank was installed ((.x. '1987). D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). (I. TANK COfNiT1.11NI'S A. t If MOTOR V1.111CLE,FUEL,check box I and complete items B& C. 2. If not MOTOR VE'LlICLE 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 FUF'I.(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 1 is NOT checked in A. III- TANK CONSTRUC'T'ION-MARK ONE 17177M ONLY IN BOX A, 13,C&D 1. Check only one item in 'TYPE OF SYSTEM,TANK MATERIAL,INI'ERIOR LINING and CORROSION PROT17-(.TION. 2. If OTHER, 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 OTHER.print in space provided. 3. Indicate the LEAK Dii-TEC-11ON systems) used to comply with the monitoring requirement for the piping. V. TANK LEAK DE`1V.C1'1ON 1. Indicate the LEAK DEIECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANEI[IN CLOM,113 IN PI.A(M 1. ES'I1MATED DATE LAST USF.D-MON`J ll/Yl.�AR(January, 1988 or 01/88). 2. ESTIMATED QUANTFFY of HAZARDOUS SUIISTANCF remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATTMIAL?Check 'Yes'or NO'. APPIJCWI'MUST'SIGN ANT)DATE111113,FORM AS INDICATED, INSTRUCTION FOR THE 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. '.I'he 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 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 IS THE RF-STONS11311XI'Y OF 171.13 LOCAL AGENCY'11INFINSPECINT1113,FACIInY TO VERIFY TIIE ACCURACY OF 111E INFORMATION. *LIE UOCAL AGENCY IS RF-SPONSIBLI. FOR 11 IE COMPLEl[TON OF TIIE *IX)CAL AGF24CY USE ON]LY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATEID FORM-W(s)'ft)-171111 FOL]LOWING ADDRESS. SFAIM OF CAI.JFORNIA STATE WA`1TiR RESOURCES CONTROL BOARD C/O S.W.FuLF.S. DATA PRO-CT-SSING,CENI1!R P.O.BOX 527 PARAMOUNT,CA WM lop