COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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R `�• r. .. .fir .. .. .. :'torr . .. L. .g. :^,tet:!. s'�;�:�'ir+!!ri..�a •, ,. ,.. ,. 7. x,.. •, ,,r;..,, .,r l; 0 INSI'R.UCI.TONS FOR COMPLEri'ING FORM "B" GENL41W. INSTRUC"ITONS: • 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMrr CIIANGFS, REMOVALS and/or any other TANK INFORMNITON CIIANGE. 2. 'this form should be completed by either the PERMTr APPLICANT or the LOCAL AGENCY UNDERGROUND 'TANK INSPI"'OR. 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 ONE YI'EM" 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DI3A or Facility name where the tank is installed. I. TANK DPSCRIPITON - C,OMPI HrH All, TIFMS - IF UNKNOWN - SO SPLCIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. A1370789). 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.). H. TANK CON1T'•NE'S A. 1. If MOTOR VEHICLE FUEI,, check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & I:). 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 Service number), if box 1 is NOT checked in A. III. TANK CONStRUCITON - MARK ONE; rI'I?.M ONLY IN BOX A, B, C & 1) 1. Check only one item inTYPE OF SYSTE M, TANK MATERIAL, INTERIOR. LINING and CORROSION PROTEC.'TION. 2. If OTHER, print in the space provided. IV. PIPING INFORMA'TTON 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. 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK I13AK DLq`ECITON 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANIMI Y CLOSED IN PLACE 1. ESTIMA11D DATE I.ASTF USED - MONrI'II/YEAR (January, 1988 or 01J88). 2. ESTIMATED QVANITFY of HAZARDOUS SUBSTANCE remaining in thl tank (in Gallons). 3. WAS TANK FIRAP]) WIT'IT INERT MATURIAI.? Check 'Yes' or'NO'. APPLIC:AN'1' MUST ,SIGN AND DATES TIIE DORM AS INDIC AIM. INSTRUCTION FOR. TETE LOCAL AGI'NCTE5 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. rt IS THE RU7%PONSI:BHIW opnm I OCAL AGI?NCY TIIA'I' INSPECT ;S 'I1IE FACIIXI'Y TC) VEMIFY 111E ACCURACY OF 111E INFORMATION. 1I111 LOCAL AGENC.'Y IS RFSPONSMLE FOR TIII1 COMPIHIION OF'I7IE "LOCAL AGENCY USE ONI,Y" INFORMAITON BOX AND FOR FORWARDING ONE FORM "A" AND AW)CEA'IVI) FORM "B"(s) TY) 'ETI:E/ FOLLOWING ADDRFNS. STAT', OF CALIFORNIA '71'A IT1 WA17E1R RFSOURCI-S CONTROL BOARD C/O S.W.1? 11_P.S. DATA PROCESSING CI�WI ER P.O. BOX 527 PARAMOUNI', CA 90M 40 0