COMPLIANCE INFO_1992-2000 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLFT;NG FORM "B" GENERAL INSTRUCTIONS: I One Fi Fs'^ "b 4h i e i `;?r° ea,--h tank for, all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any orlht,r TANK INFOkMATzCN CHANGE. -T s t; ri hvulti to ,r-,,p el. tr4 ithe- the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. "£c5' Cr ( int clearly d' ; rE J(Sted information. 4 Use a hard point writing insTrUmert,. you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE ITEM" I Mark an (><) in the box next to the item that best describes the reason the form is being completed. 2 Indicate the DBA or, FariIii.y ritrmf, where the tack is installed. I . TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - S0. SPECIFY u w ETs tar:i. if ~i If tl::, •e -i,l a ,_irsi: nus^ber that is used by the owner to identify the tank B Ind;cate t:fie narno of the comparlY that: manufactured the tank (ex. ACME TANK MFG). T, att trig year t T nl 'i i IP ( �1 Ir:ctic,., l t° k, insta d ex. '98 f. rr. Inkiicate the tank capacity in uallons (ex. 25.000 or 10,000 etc.) II. TANK CONTENTS A. 1. IF MC)TOR VEHICLE FUFL, check box I and complete items 8 & C. 2. If nr_it MC'r),R 4LHT111' E FtJFi. , check tri appropriate box in section A and complete items B & D. f3 Chock th(, oppropriate box C Check the type of MOROR V[HICIE FULL (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 Ab 1,ra;:t. Servicke riumbrr ). if I is N01 checkod -in A. III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B. C & D Check only one item in 'YPF ()F Sr"STFM -TANK MA.TFR;AL, INTERIOR LINING and CORROSION PROTECTION. 2. If 10"HER, print; iri the spa�.e 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 DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. E:ST'MAT:D [)ATE LAST 1ISE� MOINIHr'Y[..AR (January, 19BB or 01f88) 2. ES71MAT fD Al"ANTITY of H,�Z'% DOUS SUB�-T .:ANCremaining in the tank (in Gallons). 3. WAS iANK FILLED WIN INERT MATT=.F.IAL% heck 'Yes' or 'NO' APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES Thestate under=ground storage tank.. identification number is composed of the two digit county number, the three. diUit juri-sd,ction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and carr be obtained by calling the State Board (916r 227-4303. 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 he 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 OFJHE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.