COMPLIANCE INFO_1986-1993 - Laserfiche WebLink

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INSTRUCTIONS FOR COMILLOG FORM "B" GENERAL INS7"RUC`ITONS- 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PFRmrr cnANGIN, REMOVALS and/or any other`TANK INFORMATION CHANGE. 1 2, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TXNK INSPECTOR. 1 Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF MRM: *MARK ONLY ONE ]FITM" L 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. I. TANK DF-SMP'IION - CX)MPIZITii ALL ITEMS - n? 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 10,000 etc.). 11. TANK CONJ'HNFS A. 1, If MOI OR VEHICLE FUEL, 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 & D. 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. 111. TANK C0N91'RUCnON - MARK ONE TWIM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, 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 OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECJ1ON 1. Indicate the LEAK Drill-,C`TION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMA711ON ON TANK PERMANEMIlLY CIA)SED IN PLACE 1. ESTIMATED DAI E, LAST USED - MONTII/YEAR (January, 1988 or 01/88). 2, F-511MATED QUANT171Y of HAZARDOUS SUBSTANCE remaining in the tank (in Daltons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or'NO'. APPII(YiNr MUST SIGN AND D.A71`13111113 FORM AS INDICATED. IN,S'MUCIION FOR11111 IAX:AL 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. I'FIS111E RESPONSTBU.11717Y OF 113E LOCAL AGENCY THAN INSPIX.'I'S'17111 FACH1.1'YTO VERITY '11-113 ACCURACY 01711111 INFORMKIION. THE LOCAL AGENCY IS RESPONSIBLE FOR 11113 COMP117170N OF THE *LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCINIED FORM "B"(s) TO 17HE FOLLOWING ADDRESS. STA111 OF CALIFORNIA STNI'Ll WNJUR RESOURCES CONTROL BOARD C/O S.W.E-F-P.S. DATA PROCESSING CENITM P.O. PDX 527 PARAMOUNT, CA 90723 ?* 0