COMPLIANCE INFO_1992-2002 - Laserfiche WebLink

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v INSI.'RUCLTONS FOR COMPIHfING FORM"I?" GENERAL INSTRUCTIONS: 1. One FORM "B"shall tie completed for each tank for all NEW PERMITS,PERMIT CIIANGIS, REMOVAIS and/or any other"TANK INFORMAITON CHANGL? 2. This form should be completed by either the PERMI'C APPLICANT or the T..00AL AGENCY UNDERGROUND TANK INSPECL'OR 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. '17OP OF FORM:'MARK ONLY ONE ITI:9VI' 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 DT-SC.RIPITON-COMPI.FMI All.rITNS-IF UNKNOWN-SO SPFC1IFY 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 10,040 etc.). II. TANK CONL'ENI'S A. 1. If MOTOR VI?IIICLE FUEL,check box I and complete items B &C. 2. If not MOTOR Vfs`I-IICI.,I:i 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. III. TANK CON.S717RUCITON-MARK ONE ITEM ONLY IN LIOX A,13,C&D I. Check onto one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTIIER,print in the space provided. IV. PIPING INFORMA'11ON L 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 DI4'rVCI1ON system(s)used to comply with the monitoring requirement for the piping. V. TANK LICK DI:IIT7,- [ON 1. Indicate the LEAK DEIIECTION system(s)used to comply with the monitoring requirements for the tank. VI. INI?ORMA77ON ON TANK PERMANw.my C7ASFI)IN PLACE 1. E.S'I7MNI7ED DATE LAST USED-MONTII/YEiAR(January, .1.988 or 01/88). 2. ESTIMATED QUANTITY of IIAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WTITI IiNERT MATERIAL?Check 'Yes' or'NO'. APPIICANI'MUST SIGN AND DAn,!'T7IE R)RM AS INDWATI!D. INSTRUCTION 1?OR'I1TE WC:AL AGFNCIFS 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"AA". '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 RF.SPONSTBII.ITY OF IIID LOCAL AGI?NC,'Y'I7TAT INSPIX70-VIIIE FACILrl'Y TO VERIFY'IT1L ACCURACY 0171711?INFORMA']TON. TTiE LOCAL AGENCY IS RESPONSIBIX4 FOR THE COMPIH170N OF17IE `IDCAL AGENCY USE ONLY'INFORMAITON BOX AND FOR FORWARDING ONE FORM'A'AND ASSO(TAI17.I) FORM-B-(s)TC)I1fE FOLLOWING ADDRESS. STMT OF CALIFORNIA SIATI?WAITiK KI?SOUR(TSS CONTROL HOARD C/O S.W.1: nP.S. DATA PROCESSING CHVI 3R P.O.BOX 527 PARAMOUNT',CA WM �.xeti 4,.. l•'n .. -.., - -.•a' ;.: ..r...3,i? ..fsx......v{a. $.�: .'r#ae+^7,"}-z,,.."'�. .�.9r'!:"tR 't.,.:f!:r. s.;.. .,. _.__. ._ ...._ �.�-__ -�.. r.;t•.