COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPIJ-,MG FORM "B` GINERAL INSTRUCTIONS: L One FORM "B" shall be completed for each tank for all NM. PERMr.M PERMIT C IMNGFS, REMOVALS and/or ani other TANK INFORMNITON CHANGE. 2. 'This form should be completed by either the PERMIT 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 FORM- "MARK ONLY ONE TTIM 114 L Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the D134 nr Facility name where the tank is installed. I. TANK DESCRIP'ITON C OMPIE1T3 ALL ITEMS - IF UNKNOWN - SO SPI Ml'q A. Indicate owners tank 11) # - 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? 'T'AN'K MFO.). 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 CONTENTS A. " 1:'If MOTOR VEHICI..E? FUI:,*L, check box l andleomPlete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items I3 & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (i£ 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 CONSTRUCTION - MARK ONE rILM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF SYSITM, 'TANK MXIMRIAL, INTERIOR LINING and CORROSION PROTEC71TOiN. 2. If OTHER, print in the space'provided. TV. PIPING INFORMATION t 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 DETECTION systems) used to comply with the monitoring requirement for the piping. V. TANK LEAK DEIFL*nON 1. Indicate the I,EAK DUrE,CI'ION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMNIION ON TANK PHRMANENI1Y C3 OSID IN PLAC73 A. ESTIMATED I)AT.T: LAST USED - MONTTI/YFAR (January, 1988 or 01/88). 2. PSTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WrTIE INERT MATERIAL? Check 'Yes' or'NO'. APPLICANT MUST SIGN AND DATE 11IR FORM AS INDICNITA). INSTRUCTION FOR -',QW. LOCAL AGINC."IPS The state underground storage tank identification number is composed of the two digit county number, the three uigit 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 cabling the State Board (9.16)739-2421. "file 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 RESPONSIBIL11 Y OF TEE LOCAL AGENCY 'THAT INSPECTS TTIE FACILITY '.TO VERILY 'TIIE ACCURACY OF TTIE INFORMATION. TIIH LOCAL AGENCY IS RESPONSIBLE FOR TIW COMPUaION OF 71113 `DWAL AGI? 4CY USE ON Y" INFORMATION BOX AND FOR FORWARDING ONE FORM "A` AND ASSOCIN IT?0 FORM 'B'(s) TO TTIE FOLLOWING ADDRESS. STATE:? OF CALIFORNIA STATE WNI13R RESOURCES CONTROL BOARD t C/O S.W.I7 E.P.S. - - , ; 4 i 4_: DNTA PROCESSING C F2,nUR P.O. BOX 527 PARAMOUNT, CA 90713