COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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INSTRUCTIONS F COMPLETING F " " a GENERAL INSTRUCTIONS: 1. One FORM "B" shall be completed for, each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or, any other" TANK INFORMATION CHANGE, 2. this form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. , Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE ITEM" 1. 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 DESCRIPTIONCOMPLETE ALL ITEMS - IF U • SO SPECIFY A. Indicate owners tank 10 # . If theFis 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 MFC), C. Indicate the year the tank was installed (ex, 1987), D. Indicate the tank capacity in gallons (ex, 28,000 or 10,000 etc.) Il. TANK CONTENTS A, 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B & C: 2. If riot MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B, Check the appropriate box: C. Check the type of MOTOR VEHICLE. FUEL (if box 1 is checked in A), D. Print the chemical name of the hazardous substance stored inthetank and the C.A,S. . (Chemical Abstract Service number). if box I is NOT checked in A. IIT. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C 1. Check only one item in TYPE OF SYSTEM, 'TANK MA'TERT.AL, INTERIOR LINING and CORROSION PROTECTION. 2. If OWER, print in the space provided. IV. PIPING INFORMATION I Circle A ifabove ground circle U if underground, and circcle both if app] rcable. 2. - -1 if UNKNOWN circle; or If OTHER, print in space provided 3. Indicate; the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION I.. Indicate the LEAK DETI',:M ON system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PER AENTLY CLOSED IN PLACE 1. ESTIMATED DATE L.ASI USED - MONTH/YEAR (January. 1.988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining 'in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL Check 'Yes' or, 'NO' APPLICANT MUST SIGN AND DATE THE 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. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The facility number must be the same as shown in form "A The tank numberr 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, peaseeave it bland: IT THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY' F`THE INFORMATION. THE LOCA. AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX D FOR FORWARDING ONE FORM `°A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.