COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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FNSTRUCIIONS FOR COMPLETING FORM"B" GFNERAF.INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT'CHANGES, REMOVAIS and/or any other TANK INFORMATION CIIANGI: 2. This form should be completed by either the PERMIr 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. "POP OF FORM:*MARK ONLY ONE I TI:N' 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 DIM.M ITON-COMPI.EIL ALL ITIMS-IF UNKNOWN-So SPFA IFY 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 10,000 etc.). Il. TANK CONIMNI5 A. 1. If MOTOR VEIIICI.17 FUEL,check box 1 and complete items B R C. 2.If not MOTOR VEEIICLE FUEL,check the appropriate box in section A and complete items B R D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). 1). 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. M. TANK CONSTRUCTION-MARK ONE nim ONLY IN BOX A,11,C&D 1. Check only one item in TYI'E OF SYST'EM,TANK MATERIAL,INTERIOR LINING and CORROSION PKO'I'ECI'ION. 2. if OTHER,print in the space provided. IV. PIPING INPORMA11ON 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 DSITCIION system(s)used to comply with the monitoring requirement for the piping. V. TANK LFAK Dlrll: TION 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMA11ON ON TANK PERMANFNII Y CI OSF.D IN PLACE 1. ESTIMATED DATE LAST USED-MONTIIIYEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of IIAIARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WrIll INERT MATERIAL? Check 'Yes'or'NO'. APPY I CANI'MUS17 SIGN AND DA1T?TIIE FORM AS INDICATI?D. INSTRUCnON ISR 111E LOCAL AGENCW—S 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 TIFF RESPONSIBII.m OF mm LOCAL AGENCY'I1IA'r INSPwIS'11113 FACii m TO VERIFY TIIE ACCURACY OF 1111?INFORMNITON. T1IE LOCAL AGENCY IS RE.SPONSIBI E FOR'11IEi.COMPLETION OF 1IIE 'LOCAL AGENCY USI1 ONLY*INFORMA11ON BOX AND POR FORWARDING ONE FORM"A"AND ASSC)C IATI?D FORM-W(s)TO 11IE FOLLOWING ADDRESS. STATE OF CAI.,IFORNIA STATE WNIT.iR RI SOUR(ES CONTROL BOARD C/O S.W.I1.11P.S. DATA PROCI:WSING CMl-MI R P.O.BOX 527 PARAMOUNT,CA 9t M i • t3�r�ar;l7sw A�Al�,..a�t E`'— �..:�," •pail' A.'��i� 'S.�i�b��rsrts,:est'_�.�.�asr4`mer_;ltr*�l^3.2,�'S°sLd'"�.•i5��""— ....,..._.we..,. ...wa:::b-'.._�