COMPLIANCE INFO_FILE 9 - Laserfiche WebLink

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_ 'ate::_v:-v�- •r^-us.-t+r�-r �-....►,,.'_c..r-T.-�---�.+..r.�.,�, _ •- INSTRUCTIONS FOR COMPLE'T'ING FORM"B" GENERAL INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGFS, 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. NSPECTOR3. 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 ITT?M" 4 1. Mark an (X)in the box next to the item that best describes the reason the form is bging completed. 2. Indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION-C6MPI.I M 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.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. 1984 D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.7. H. TANK CONTENTS A. 1.If MOTOR VEHICLE FUEL,check box 1 and complete items B&C. 2.If not MOTOR VEHIgE FUEL,check the appropriate box in section A and complete items B&t D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). D. Priht the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service number),if box 1 is NOT checked in A. IIL TANK CONSTRUCTION-MARK ONE ITER[ONLY IN BOX A,B,C&t D 1. Check only one item InTYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION, 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 OTHER,print in space provided. 3. Indicate the LEAK DETEC13ON system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DE EGfION i I. Indicate the LEAK DE'T'ECTION system(s) used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. 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 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)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 RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACII I Y TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RF.SPONSIB E FOR THE COMPLEIION OF THE "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.F.YS. DATA PROCESSING CENTER P.O.BOX 527. PARAMOUNT,CA 9072:1