COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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m INSTRUCTIONS FOR. COMPLETING FORM " <° 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. r 3. Please type or print clearly all requested information. 4.- Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: K 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 DBAFacility name where the tank is installed. . I: T DESCRIPTION AOMPLETE ALL ITEMS ® IF UNKNOWN w SO SPECIFY A. Indicate owners tan�ID # - 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). D. Indicate the tank capacity in gallons (ex. 25.000 or 10,000 etc.) II. TANK CONTENTS A. 1. I1" 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 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 Ae B. , 1. Check only one item irM TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LIMING and CORROSION PROTE,- ION. 2. If 01HER. print in the spice provided. IV. PIPING INFORMATION 1 . Circle A if above (;round circle U if underground,. and circle both if applicable. If UNKNO'W'N circle; or if OTHER. print in space provLded' ?. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping: V. TANK LEAK DETECTION 1. Indicate the LEAK D r7TECrION systems) used to comply with the monitoring re;uiremertts for the tank. VI , INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST 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 The state undo Around 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 (915) 227-4303. The facility number, mustbe.the same as shown in form "A". The tank number may be assigned by the 'l,ocal 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 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.