COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

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INS`IRUCITONS FOR COMPLHFING FORM"B" GENERAL INSTRUCTION& 1. One FORM "B"shall be completed for each tank for all NFW PERM171N,,PE'RMrF ClIANCF-S, REMOVAIS and/or any other TANK tNI?ORMATION(,7IIANGF- 2. This form should be completed by either the PERMIT APPLICANI'or the LOCAL AGENCY UNDI.IRGROUND TANK INSPW11OR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. ,rop(Nei'ORM:'MARK ONLY ONE IiM- 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the D13A or Facility name where the tank is installed. 1. TANK DF-SCRIY170N-COMPLUIM All,rFFMS-IF UNKNOWN-SO SP13CIFY 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.). H. TANK(30NI73NI5 A. 1. If MOTOR 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 & 1.). 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 CONSI.RUCIION-MARK ONE r"ONLY IN BOX A,B,C&1) J. Check only one item in"TYPE OF SYSTEM,"TANK MATERIAL, INFERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING fNITORM/1I7ON 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTIIER,print in space provided. 3. Indicate the LEAK DE7ECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LIM DETECT ION L Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. V1. INIk)RMATION ON TANK PERMANFNI'LY CLOSED IN PLACE I. ESTIMATED DATE LASE'USED-MONFII/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED Wrl'If INEKI I MATERIAL. Check 'Yes'or'NO'. APPLICANT MUST SIGN AND DATI11111i FORM AS RQ)ICKIED. 1N,S'MUCI1ON FOR MIE LOCAL AGEN(III-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. rr Is niE u7spoms1131Im OF 11IF LOCAL A(jINCY T1IK1'INSPECV S11114.FAC.TI.XrY J.'()Vl?Rfl-'Y1711:1 ACCURACY OF'ITIE INFORMNIION. 771E LOCAL AGENCY IS RESPONSIBLE R)R 1111i COMP11117ON OF 171E "LOCAL AGENCY USE ONLY"INI7ORMA711ON BOX AND FOR FORWARDING ONE FORM*A*AND ASSOCIATED FORM'B'(s)I)O1111i FOLLOWING ADDRESS. SrAIE 017 CALIFORNIA WAIT3R RESOURCES(X)NI701,BOARD CIO P's. DATA Pio&--,sm cmvrm P.O.BOX 527 PARAMOUNT,CA 90723