COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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INS. U('IICINS ICOR COMPL17TING FORM �W GI.,,-NIIRAL INSI7RUCT11ONS. 1. One FORM "I3" shall be completed for each tank for all NFW IAF? 171N RF?R rr C31ANGES7, REMOV IS and/or any other TANK INIj R °IION C IANG1 2. 'Phis forret should be completed by either the ISI:; r1' APPU ' I' or the LOCAL A(3ENC;7Y UNDERCIR.C)E,IN13 T N INSPECTOR- 1 NSP 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. "MARK ONLY ONE mim" 1. bark an (%) 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. €. TANK 1)E SCRIIgF1ON - COMPLETE .r PILI, r1li S - W UNKNOWN - SO SPE0FY A. Indicate owners tank. ID # - If there is a tank number that is used by the owner to identify the tank (ex. FiB70789). 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). I:). Indicate the tang; capacity in gallons (ex. 25,000 or 10,000 etc.). II. "TANK (X)N TENTS A. 1, If MOTOR !/E:: 3IIC,I..I: FU1,1, check box 1 and complete items 13 & C. 2. If not M O'I'OR VFIIICLI TUI I.,, check the appropriate box in section A and complete items €3 & D. B. Check the appropriate box, (:. Check the type- of MOTOR VEHICLE E E'UI L (if box I is checked in ft). I). Print the chemical name of the hazardous substance stored in the tank and the (:A.S.#. (C"hem;cal Abstract ;service number), if box I is No,r checked in A. III, TANK C)N9I7RUC"1ION - MARK ow rivm CImx IN Rott, 13, C: & F7 1.. Check only one item inTYPE 0FSYSrE1M,TANK MATT: Int' L, E' I'E;RICSR I ININ£3 and CORROSION PRi TEC1 10N. 2. If OTHER, print in the space provided. FV. PIPING INFOR NPICIN 1. Circle A if above ground; circle U if underground; and circle both if applicable. ". If UNKNOWN, circle; or if 01'11111 , print in space provided. 3. Indicate the LE x i3E:'E ECI"#ON system(s) used to comply with tate monitoring requirement fgzr the piping. V. TANK IA.iAR 1)I?'IECi`IION L Indicate the LEAK 1)EITX"I710 system(s) used to comply with the monitoring requirements for the Ilk. VI. INFORMSTION ONTANK PER ANEMI'LY (MOSIR) IN MACE 1. E-4I'IM TED DATE,, 1AS'1' USED - MON'"I'EI/"FAR (January, 1988 or 01/88). 2. I':SFIi4tA`I'ED C)UA1' I`ITY of EiRC,'kRE?t)US SUI3EiI'ANCEr remaining; in the tank (in Gallons). 3. WAS TANK E'II„1.110 WITH lNTER'I' r1'a`ERbXL? Check 'Yes° o'r 'N£)', PLIC SPI' U'Sr SIGN AND D I"E? "111€1 17ORM AS INDICATED. INSTRUC `17ON ISR 11111 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. 'ne facility number must be the same as shown in Form "A". The tank number may be assigned by the local agency, however, this number trust be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. t'FIS '11111 RESPONSIBIIXIY OFT1111 I,0(:AI, (I (Y '[°FIAT" INSPW-I 7'IIF? FAC 1I: 1T V) VERIFYTIIE (X.'I3 C'Y OF 711, i I$C)R JVI`€ON. `I11E LOCAL AGEN(W IS RESPONSIBIE FOR111F C O PLInION ()Ir'I71E "I.C? ” :A ACIENCTY USE ONLY' INFORMSHON J.3OX AND FOR ICOR a1RI3ING ONE FOR "A" AND S,SOC °€`1: D FORM P "13"(s)1.011111 F 011,0 INCI eiI)i RE&S. 917VI713 OF ('.ALIT RNI 9i'ItT1 WX11,7R RF—,SOUR(-!ES C:() 'R L BOARD C/o es. s Ia p.S. D,KFA PROCINNSING C7INHIR P.O. i3f) 52°7