COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS FOR COMPLVITNG FORM"B" GENERAL INSTRUCITONS 1. One FORM "B"shall be completed for each tank for all NEW PERMrTS,PERMrr CHANGES, REMOVALS and/or any other TANK INFORMA11ON CIIANGI? 2. This form should be completed by either the PERMrr 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. 1. TANK DFSCRIP110N-C,OMPi..EIM All,nVAS-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.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.). 11. TANK CON ENI5 A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B &C. 2. If not MOTOR VELIICLE- FUEL,check the appropriate box in section A and complete items B& D. B. Check the appropriate box. C. Check the type of MOTOR VE:HIC:LI 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 1.is NOT checked in A. 111. 'TANK CONSI'RUCTION-MARK ONE nim ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR I.,INING and CORROSION PRO,rECl•ION. 2. If OTHER,print in the space provided. I.V. PIPING INPORMAIION 1. Circle A if above ground; circle U if underground;and circle both if applicable. 2. If UNKNOWN,circle; or if OTIIE3R,print in space provided. 3. Indicate the LEAK DE;ITCIION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DI3 EC CON 1.- Indicate the LEAK DE ITCTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANIN`[.7:Y CLOSED IN PLACE 1.. ESTIMATED DATE LAST USED-MONTII/YE:AR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZA.RDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILL'FD WTI II I vTR'I•MA'Tf3RIAI.,? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE 17111 FORM AS INDICA1.1D. INSTRUCTION FOR'HIE LOCAL.AGENCII?S 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)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 TI1E RFSPONSIBLI..Try OF ITII,IAC.AL AcENcY ITIAT INSPF.C1:4171I?FA(m rrY TO VERII•'Y 711E ACCURACY OF 111E INFORMATION. 111E LOCAL AGENCY IS RESPONSIBLE FOR 111B COMPLEITON Off TIIE "LOCM,AGENCY US13 ONLY'I.NFORMAIION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIN11?1) FORM-W(s)TO 1.11E FOLLOWING ADDRESS. STATE OF CAIJM4 RNIA SI'JVFE WA11?R RESOURCIN CONI'ROL BOARD C/O S.W-I?Ir PS. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 '�:�..%ss�Y"• �+• �+�� _....� � -Y � �.#�:: t�I?'•.q .+�h' yr �. :. _ �:.. ' a w. <• ..