COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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,owlet <V. 1.�, le� 1-11t7-,,- -�- I � ---- --z x,� INSIRUCIIONS FOR COMPLLMNG FORM "B" GENERAL INSTRUCTIONS: 1, One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any otherl'ANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPIICANT or the LOCAL AGENCY UNDERGROUND 'TANK INSPECTOR. 3. Please type or print clearly all requested infornfation. 4. Use a hard point writing instrument, you are making 3 copies. TOP, OF FORM: *MARK ONLY ONI I ITEM' ,1. Mark an (X) 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. 1. TANK DESCRIPTION - COMP1,91M All, Mt MS - IF UNKNOWN - SO SPFX3FY A. Indicate owners tank 11) # - 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. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). 11. TANK CONIl[Wn' A. 1. If MOTOR VEHICLE I:VEL, check box I and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & 1). B. Check the appropriate box. C. Check the type of MOTOR V14.1-11CI-E FUEL (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 Sezvice number), if box 1 is NOT checked in A. 11 . 111. TANK CON,%-MUC11ON - MARK ONE rnm oNtm iN uox A, B, c & D 1. Check only one item in 'TYPE OF SYSTEM, TANK MNIT,RIAL, INTERIOR LINING and CORROSION PROTECIION. 2. If. OTHER, print in the space provided. IV. PIPING INIK)RMKnON 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 I)LTEC11ON system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DENW, 11ON 1. Indicate the I.JAK D13 I`ECI`ION system(s) used to comply with the monitoring requirements for the tank. V1. INFORMATION ON TANK PERMANEN17LY CLOSED IN PLACE 1. F-S'IIMXI'ED DATE LAST USED - MONIII/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Giallons). 3. WAS TANK FILLF"D W1111 INEliff mA:rERIAU? Check 'Yes' or 'NO'. APPLICANT MUST SIGN AND DATE 111111 FORM A,% INDICATED. INSTRUCTION FORT][IE LOCAL AGENCIES The state underground storage tank identificatiod 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 c6nfain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT N TILE RESPONSIB1111-Y OF TIDE LOCAL AGENCY'11IAT INSPECTS 111E FAC111TY170 VERIFY 1711.1 ACCURACY OF TIIF INFORMATION. IIIE LOCAL AGENCY IS RESPONSIBIll FOR 11113 COMEPLInION OF THE "LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM 'A" AND ASSOCWI1-,D FORM 'B'(s) TO 11W. FOLLOWING ADDRESS. 917AI'F, OF CALIFORNIA SFATV. WATER RESOURCES CONTROL BOARD C/o &W.111-fPs. DATA PROCESSING, CENITR P.O. BOX 527 PARAMOUNT, CA 90M 11t