COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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i IIS—I'RUCITONS FOR COMPLI PING FORM *B" GI3NERAL IN. RUCIIONS: 1. One FORM "B" shall be completed for each tank for all NEW PERMRIS, PERMTr CITANGFS, REMOVAI: `i and/or any other TANK. INFORMAIION CIViNGE. 2. This form should be completed by either the PERMiI: APPLICANT' or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF DORM: *MARK ONLY ONE IWW 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 DPSCREP'IION - C.OMP11117 A11. TrFMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - 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 10,0ti0 etc.). H. TANK (ANT FNIN A. 1. If MO'T'OR VEHICLE FUEL, check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FULL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FULL (if box 1. is checked in A). D. Paint 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. III. TANK CONSTRUCTION - MARK ON13 n -FM ONLY IN IiOX A, I3, C & 1) 1. Check only one item inTYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER, print in the space provided. IV. PIPING TNll?ORMA11ON 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if O'T'HER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETFCIION L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VL INFORMATEON ON'IANK PERMANI.WMY CLOSED IN PLACE t . 1. ESTIMA'ITD DATE I..AST USED - MONTI-I/YEAR (January, 1988 or O' %N). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK I II(1 (D WI1'1-1 INERT MATERIAL? Check 'Yes' or 'NO'. APPI1C:AN'r MUST SIGN AND DATE'I13E FORM AS INDICATED. TNSTRUC'I1ON 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)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 TIIE R&sw)NsjBu i f OF 111E LOCAL AGI:TICY T1IA1" INSPE(7I:S '11TE3 FAC.'II.TTY 11) VERIFY 'I11E ACCURACY OF 111E INFORMAIION. TILE., I..00AL AGENCY IS RESPONSIBLE FOR 111E COMPI..ITI1ON OF THE "LOCAI. AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND AS.SOCINIfED FORM "13"(s)1Y) 711113 FOLLOWING ADDRFSS. S1:A1 1 OF CALIFORNIA STATE WA'IER RESOURC'I-S CONI701, W)ARD Ci°C) DATA PRO(-TSSEN("a (.IWFER P.O. BOX 527 PARAMOUNI:, CA 90723