COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM ''B'' GENERA[ INSTRUCTIONS: l One FORM ^B" shall be completed fnr each tank for all NEW PERNITS, PERMIT CHANGES, REMOVALS and/or any other TANK INFORMATION CPLANGE 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER[RDUND TANK INSPECTOR 3. �Plemse type or print clearly all requested'informot1on 4Use a hard point writing instrument. you are making 3 copies, TOP OF FORM: 'MARK ONLY ONE ITEM" 1 Murk on (X) in the box next to the item that best describes the reason the form is being completed, 2Indicate the DBA or Facility name where the tank is installed. T. TANK DESCRIPTION ' COMPLETE ALL ITEMS ~ IF UNKNOWN ~ SO SPECIFY A. Indicate owners tank lD 0 ' if there is 8 tank number that is used by the owner to identify the tank (ex. A870789) 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. 35.000 or 10.000 etc,) TT. TANK CONTENTS A. I IF MOTOR VEHICLE FUEL, check box l and complete items 8 & C 2 If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D B. Check the appropriate box C. Check the type of MOTOR VEHICLE FUEL (if box I is checked in A), D Print the chem1cal name of the hazardous substance stored in the tank and the C.A S.#. (Chemical Abstract Service number). if box l is NOT checked in A, iii. TANK CONSTRUCTION ' MARK ONE ITEM ONLY IN BOX A. B, C & D l Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2 If OTHER. print in the space provided IV. PIPING INFORMATION / l Circle A if above ground circle U if underground, and circle both if applicable, Z 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 l indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements f0r the tank, VT. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE l ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) 2 ESTlMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (1n Gallons), 3 WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO' APPLICANT MUST SIGN AND DATE THE FORM AS TNDTCATED, 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) 227-4303 The facility number must be the same as shown in form ''A^ The tank number may be assigned by the local agency, huwever, this number must be numerical and cannot contain an alphabet. If the local agency prefersthe 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 OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR F8RWRDING ONE F0kN ^A~ AND ASSOCIATED FORM 04s) TO THE FOLLOWING ADDRESS.