COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

Home Browse Search

X75�.- --a -�_ -+..-.n.v.�-r�..-�o.--r.. ,.�--�-. '"___-+- •+Ren^;w+:c v+f'v"*++�'�'.'-+.p. --+pp-sip�.r--�.'s..r�-®-. _ ...i,-.-....r..* T_ -s.._....,.�,r-.'-,,,.,,....;�_ t.�.�.. � INtiFRUCLIONS FOR COMPIA. FORM"B" ~ GENERAL 1NS1RUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMI'I.N,PERMIT(RANGES, REMOVALS and/or any other'TANK INFORMATION CHANGE. 2. 'Phis form should be completed by either the PERMIT APPI ICANL'or the LOCAL AGENCY UNDERGROUND TAINK INSPECIY)R. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORINT: "MARK ONLY ONE ITI..W" 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. I. 'TANK DES -COMPIHMI All.111?MS-IF UNKNOWN-SO SP14X3FY 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.). II. 'TANK CONIT:NIS A. 1. If MOTOR VEI11 I.1 FUEL.,check box 1 and complete items I3&C. 2. If.not MOTOR VEHICI,,F:F'UI-11,check the appropriate box in section A and complete items B & D. 13. 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. III. 'TANK CON.STRUCIION-MARK ONE 17T:?M ONLY IN BOX A,B,C&D 1. Check only one item in*TYPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION PRO'1*3CTION. 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 O`TIIER,print in space provided. 3. Indicate the LEAK DEiI'F3CTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DLFIX711ON 1. Indicate the I.LAK DF,'IT`TION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANEMILY Cl[A)SED IN PLACE 1. I:: TIMA'I*D DATE LAST USE D-MON1'IF/YI::AR(January, 1988 or 01/88). 2. I:,`;FIMATED QUANI:'I"IY of HAZARDOUS SUI;SI'AN(:E remaining in the tank (in Gallons). 3. WAS TANK FILLEI) WITH IN1.,11T MATT:RIAL? Check 'Yes'or'NO'. APPLICANT MUST SIGN AND DA114 71111 FORM AS INDI(WIT0. 1N9I'RUCI7ON FORIIIH IOC AL AGENCIES The state underground storage tank identification number is composed of the two digit county number,the three di;it 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. ITT is1TIP RFSPONSIBILTI'Y OF THE LOCAL.AGENCY 7.1IAT INSPEC'TS'11iP FACILLTY`I'O VERIFY 111E ACCURACY OF`IIIE INFORMATION. 77II?LOCAL AGENCY IS RESPONSIBLE FOR*'IIP COMPIIiI1ON OF 11IE *LOCAL AGENCY USE ONLY"INFORMN11ON BOX AND FOR FORWARDING ONE FORM"A"AND A.SSOCINIT?D FO "B"(s)TO-11111 FOIlA)WING ADDRESS. STATE OF CA11FORNIA 9I'A'I7:WATER RESOURCES CONTROL BOARD C/O S.W.I?E.P.S. DATA PROCESSING C ENITR P.O.IX)X 527 PARAMOUNT,CA 90723 J