COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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1.1 INSI'RUCIIONS FOR COMPLVIING FORM *B* GENERAL INSTRUCTIONS: I. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CIIANGES, REMOVALS and/or any other TANK INFORMA711ON CHANGE. 2. This form should be completed by either the PERmrr APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECT OPL 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OFFORM: *MARK - ONLY ONE 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. L TANK DESCRIVIION - COMPLVni A1.1. r111MS - 117 UNKNOWN - SO SPI3C31?y A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to .identify the tank (ex. A.1370789). 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.). IL TANK CONTI.Wn, A. 1. If MOTOR VEHICLE FUEL, 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 & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE 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 Seivice number), if box I is NOT checked in A. I I 111. TANK CONS-MU(:I1ON - MARK ONE rn%4 ONLY IN--ROX A, B, C & 1) 1. Check only one item in'rYPE OF SYSTEM, 'TANK MA'!T-,RIAI,, INTERIOR LINING and CORROSION PRO'T'ECTION. 2. If OTHER, print in the space 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 DL7rECI1ON system(s) used to comply with the monitoring requirement for the piping. V. TANK I.MK DH11VC11ON 1. Indicate the LEAK Dl.",�T.'ECYIONsystcm(s) used to comply with the monitoring requirements for the tank, V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA01, L ES`I1MKI`ED DATE LAST USED - MON`111/YFAR (January, 19M or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANC[I., remaining in the tank (in Gallons). 3, WAS TANK FILLED WFIYlI INI:,1'R`-1 MATERIAL? Check'Yes' or'NO'. APPLICANT MUST SIGN AND DA11,7111E FORM AS INDICA TEED. INYMUCTION FORnIE LOCAL AGENCIES The state underground storage tank identificatioti 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 (91,6)739-2421. The facility number must be the same as showQ in form "A". The tank number may be assigned 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. IT IS TILE REsPoNsiBn.n",( OF ITIE LOCAL AGENCY TIIAT INSPECTS TIIE VACIIXI-f TO VERIFY 11111 ACCURACY 017 TITE INFORM)VpION. 71fE LOCAL AGENCY IS R1SPONSIBI.1.1 MR 7171111 COMPL1.,nON OF 1711:1 'LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCINIED FORM -Ir(s) TO -111E FOLLOWING ADDRESS. STYVIT; OF CA1117ORNIA -SMATE WAITR RESOURCES CONTROL BOARD C/o S.W.unp-S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT", CA 90M Jow 'OV