COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS FOR COMPLETING FOR "B" V 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. - nformation.4. - Use a hard point writing instrument, you are making 6 copies. TOP OF FORM: 'MARK ONLY ONE ITEM" 1. Mark an (k) in the box next to the item that best describes the mason the _form is being completed. 2. Indicate the DBA or facility name where the tank is installed. I, ,,DECRTION - COMPLETE ALL ITEMS - 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 (ex. A870789). R B. Indicate the name of the company t'nat manufactured the' tank (ex. ACME: TANK MFG), C. Indicate the year the tank was installed (ex. 1987), D, Indicate the tank capacity in gallons (ex, 25.000 or 10,000 etc.) II. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box I 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 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 CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. Gs C & D 1. Check only one item in TYPE OF SYSTEM. TANK MA''ERI,AL: INTLRIOR LINING and CORROSION PROTFCIIDN. 2. If 011-1LT , print in the space, provided. IV. PIPING INFORMATION 1 Ci cue A if above ground circle U if underground- and circle both if applicable. 2 - If UNKNOWN circle; or if OTHER, print in space provfded' :?. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for, the piping. V. WANK LEAK DETECTION I., Inriicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE p 1 ESTIMATED DATE L.ASI USED - MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS DANK FILLED WITH INERT MATERIAL—? Check 'Yes' or, 'NO' APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES Tlsfa state underci:round storage tack identification 'nuirber 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 nurrsbers 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 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 Beard to assign the tank number, please leave it blank- I - IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL 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.