COMPLIANCE INFO_1984-1994 - Laserfiche WebLink

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INN,MUCI7ONS FOR COMPI..I?I1NG FORM"13" GENERAL INSTRUCIIONS: I. One FORM "B"shall be completed for each tank for all NEW PERMITS,PHRMUT CIIANGI?S, RFMOVAI S and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMUT APPIIC'ANI'or the LOCAL,AGENCY UNDERGROUND TANK INSPECIVR. 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 ONI,'M.M" 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.:i - 2. Indicawthe DBA or,llacility name where the tank is installed. L TANK DESCRIPTION-CDMPLFU1t ALL 1'i'I.MS-117 UNKNOWN-SOSPBD1'FY A. Indicate owners tank 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.x`•,000 or 10,000 etc.). IL. TANK CONI VIS A. 1. If MOTOR VEHICI:F3 FUEL,,check box 1 and complete items B&C. 2. If not 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 VERICI..E 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`ycrvice number),if box I is NOT checked in A. III. TANK CONS11tUCI10N-MARK ONE firm ONLY IN BOX A,B,C&D 1. Check only one item in'TYPEi 017 SYSTEM,TANK MA•17ERIAL,INTERIOR LINING and CORROSION PRO'1`ECI10N. 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 01IIEK print in space provided. 3. Indicate the LEAK DE'I'EC11ON system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DE'I"ECIIO system(s) used to comply with the monitoring requirements for the tank. VL ugmRMATION ON TANK PERMANENII Y CLOSED IN PIACE 1. ESTIMATED DATIH LAST USED-MONTHjYEAR(January, 1988 or 01/88). r `r 2.- ESTIMATED OUAN7I1TY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WTI'II INERT MA7:'ERIAL?Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE'111E FORM AS INDICATED. INSTRUCTION FOR TME LOCAL AGENCHS 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(91.6)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 RFSPONS[BIIX17Y OF TIFE I..00AL AGENCY THAT INSPFZJS TILE FAC 11 TTY TO VERIFY TIIE A(=RACY OF TME INFORM)V110N. "Ili 1A)CAI,AGENCY IS RESPONSIBLE FOR THE COMPL13TIO 1 OF TIIE "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND AS5k.1Cl[A1'ED FORM"B"(s)TO THE FOLLOWING ADDRESS. STATI?OF CALIFORNIA STALL WATER RESOURCES CONTROL HOARP, . 7 ►a, C/O S.W.FL F PS. DATA PRO(MSSING CENITIR P.O.BOX 527 PARAMOUNT,CA