COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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DUMUGTIONS FOR COMPLETING FORM "B" GENERAL HiSIRUCTIONS: 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, KIRMIT CHANGES, REMOVALS and/or any other TANK INFORMATION CIIANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSSPECPOR 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 ITEM" I. 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 DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPBCWY 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.). A. 1. If MOTOR VEHICLE, FUEL, check box 1 and complete items B & G 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 CA.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK CONSTRUCTION - MARK ONE ITEM 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 systems) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yee or 'NO'. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. U4S1`RUCIION FOR THE LOCAL AGENCIES 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT 949PBCIS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RIj ONSIBLE FOR TETE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(S) TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CANI`ROL BOARD C/O S.W.&F P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723