COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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INSIRUCIIONS FOR COMPLA FORM *B* .0 GFNI WAL INS-17RUC-111ONS- 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERmn'APPLICAN17 or the LOCAL AGENCY UNDERGROUND TANK INSTBCTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM. *MARK ONLY'ONH TMM* 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 DESCRIPTION - COMPLE11i All I, ITEMS - IF UNKNOWN - SO SPFC1FY A. Indicate owners tank 10 # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). 0, . 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 30,000 etc.). 11. TANK CONIIINIS A. 1. If MOTOR VEHICLE 1:71JEL, check box 1. and complete items B & C. 2. If not MOTOR VEHICLE FUI.,"L, check the appropriate box in section A and complete items B & 1). B. Check the appropriate box. C. Check the type of MOTOR VI31-IICLI-1 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 Scivice number), if box I is NOT checked in A. Ill. TANK CONSTRUC11ON - MARK ONE mem ONLY IN tpx & B, c & I) 1. Check only one item in TYPE OF SYSTEM, 'TANK MA:IT!,RIAI,, INTERIOR LINING and CORROSION PROTECTION. 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 0111ER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LMK DHITC11ON '110N s ' it14 the monitoring requirements for the tank. 1. Indicate the 1.11AK IN."TEC , ystem(s) used to ��mpfy w] C, V1. INFORMATION ON TANK PERMANFMI1,Y CLOSED IN PLACE L ESTIMATED DATE LASTUSED - MON7111/YFAR (January, 1088 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLI.3T) WHII INERT MATERIAL? Check 'Yes' or 'NO'. APPlIcAmr MUST SIGN ANT) DAT`; TIH3 FORM AS INDICA 1Eft IN',';IRXJ('IION FOR TI IF, LOCAL AGENCIES The state underground storage tank identificatiori 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 contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS TIM, RESPONSIBUM 0111711.11 LOCAL AGENCY ITIAT INSPECI5111E FACIIZITTO VERIFY 17111 ACCURACY OF ITTE INFORMATION. 111E LOCAL AGENCY IS RESPONSIBI,X1 FOR THE COMIPIP11ON OFT11E *LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCINIED FORM -Ir(s) TO -171F. FOLLOWING ADDRESS. S'I'XITi OF CAI, FORNIA STATE WATER RESOURCIiS CONTROL BOARD C/o S.W.I.1-Er-S. DATA PROCINSING C1WM4R P.O. BOX 527 PARAMOUNT', CA 90723