COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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►"",'"' '►"�"F'S" r 4a '_::.k x^_<.. �'T":`c,: ." : F.:-;+ . aF."`^`?;"*` .,a" "" ups. _ -:r^�' ;sr: `.�,+t-��" eZ v INSTRUC 11ONS FC)R C:CWP.1, l'1NG PORM"B" GENERAL 1 S1"Fat.f tOlvti: L One FORM "B"shall be completed for with rank for all NEW pf"WrlS, PERMET CHANGES, 12Ia141t:?t'rlP:S:incl,or any other'TANK INFORMATION C:IIANGE 2. This form should be completed by either ilie PERMIT APPIlC AN•t',sr the L,OC'.AL AGENCY UNDERGROUND TANK INS'PEC'TOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you vre making 3 copies. TOP OF FORM: "MARK ONLY ONE?IL13M" 1. Mark an(X)in the box next to the item ihs.t')cst describes the reason the form is being completed. 2. Indicate the DBA or Facility name where 4"^e rank is installed. L TANK DE SCRII"LION-COMP1E1,17 All,rITUS-YL' .JNKNOWN-SO Sl`t?a.IFY A. Indicate owners tank 117 #-If there is -umber that is w,-A, t:ic owner to identify the tank (c:x.All 0 7SQ). B. Indicate the name of the company that r,, ured the tank `1"TANK MFG.), C. Indicate the year tN !.mk-was installc,i I). Indicate the Tank capacity in gallons (ex. .: - ?d},fffls;tc.p- 11. TANK.CONI1?NIS A. 1. If MOTOR VEHICLE FUE;I<,check box 1 and complete items I?& C. 2.If not MOTOR VE"HICLL FUEL,check the appropriate box in section A and complete items B R I). B. Check the:appropriate box. C. Check the type o(MOTOR VEHICLE,FUE'l,(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. IIL TANK CON91'RUCITON-MARK ONE rl'E3M ONLY IN IBOX A,B,C&D 1. Check only one item in'TYPE OF SY91'EM,TANKMATERIAL, INTERIOR LINING and CORROSION PROTEIC110N. 2. If OTHER,print in the space provided. TV. 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 DE7IIX7nON 1. Indicate the L.FAK DETECTION system(s) used to comply with the monitoring requirements for the tank. V1. INFORMATION ON TANK PIIRMANEN1'LY(/LOSEE'D IN PI.AC E I. FSITMATED DNIT.LAST USED -MON"I'II/YF,AR(.January, 1988 or 01/88). 2. ESTIMATED ED QUANTITY of HAVARDOUS SUBSI:ANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WTI'H IN7:R1'MATI:;RIAI.,? Check'Yes' or'NO'. APPLICANT MUST SIGN AND DA'IM TIIE FORM AS INDICATED. IM"WRUCITON FOR111E 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 assi=gned 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. ri'IS THE RLSPONSTBII.r1'Y OF T1111 LOCAL AGENCY T IVVF INSPECTS 111E FAC:II.II'Y TO VERIFY 111E ACCURACY OF111E INI?ORMA'.ITON. TIIE LOCAL AGENCY IS RFSPONSIBIM FOR1I1E C OMPLSITON OF"1111 *LOCAL AGI.NC'Y USE ONLY"INIDRMA71ION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC:IA"ITD FORM"B"(s)1-01711i FOLLOWING ADDRESS STA'IT OIr CAl,1FORNIA S['t11 E WA717ER R1:SOURCES CONTROL BOARD C/o s.W.F E?P.S. DATA PROCT?S.SING 0WHIR P.O.BOX 527 PARAMOUNT,CA 90M