COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

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TN,';1`RUC'I1ONS FOR COMPLETING FO *B* GENERAL IN,%1'RUC11ONS:- 1. One F)RM "B" shall be completed for each tank for all NEW PERMYI'S, PI!Rmrr CHANGES, REMOVAI-S and/or any other TANK INFORMA71TON CHANGE I : 2. 'Phis form should be completed by either the PERMI I' APPLICANT' or the LOCAL AGENCY UNDERGROUND TANK INSPI.W.170R. 3. Please type or print clearly all requested information, 4. Use a hard point writinginstrunient, you are inaking 3 copies. 'POP OF FORM- "MARK ONLY ONE rimm* 1. Mark an,(X) in tete 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 1313SCRIV1710N - COMPLEMP All, r11zMS - 117 UNKNOWN - SO SPIEXIFY A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank (ex. A1370789). B. Indicate the name of the company that manufactured the tank (ex. ACM14 TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). 1). Indicate the tank capacity in gallons (ex. 25,000 or 10,000 ete.)'. 1111. 'TANK WNIFNINS A. 1. If M061"OR VEHICLE FUEL, check box 1 and complete items B & C. 2. If not M0'I`OR VE'llICLE FUEL.,, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of M0'IX.)R VEHICLE FUEL (if box I 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 I is NOT checked in A. ITL 'TANK (Y)NS`1'RUC`I1ON - MARK ONE rl'FM ONLY IN BOX A, B, C & D 1. Check only one item in 'TYPE, OIC SYS'1'IgM, '1'ANK MA'IT.,.RIAL, INTERIOR LINTING and CORROSION PRO'11`1(711(1\' 2. If C.YTIIEk print in the space provided. TV. PIPING INFORMA7171ON 1. Circle A ifabosvc ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle-, or if O'DIER, print in space provided, 3. Indicate the LEAK DF'I'F,C-110N system(s) used to comply with the monitoring requirement for the piping. V. 'TANK TEAK DLrIT!X-'IION 1. Indicate the LEAK DE -11 -NA I 10N system(s) used to comply with the monitoring requirements for the tank. V1. INFORMA71ON ON TANK. PEMMANENFIX CLOSED IN PLACT 1. FS11MA11"D DA'171?, 1AS1'USED - NIONrl"JI/YE"R (.January, 1988 or 01/88). 2. F`I'IMAn3D QUAN'1l'.17y of IWARDOUS SUBSFANCE. remaining in the tank (in Gallons). 1 WAS TANK FILLED wriii I[Nfua mn.,RIAL? Check 'Yes' or 'NO'. APPTICANTI'MUS17 SIGN AND I)XIM7171111 FORM AS INDI(WIED. INSTIRUCIION FOR'I'llit LOCAL AGINCIE-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. 'I he 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". 'I'lle 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. r.I`IS 11193 RE!,SPONSIBRTIN OF "11113 LOCAL FACILfff 71,0 VERJF`Y WE ACCURACY' OF *171TE INFORMATION. 111E z-OCAL AGENCY IS RESPONSIBIX. FOIL 1'1111 COMPLETION OF'I11E '1,OCAI, AGE�NCY USE ONLY' INFORMA'110N 13OX AND FOR R)RWARDING ONE FORM 'A' AND ASSOCIIVIED 14X)RM -13-(s) 1`01111.1" FOLLOWING ADDRRS.S. "ENIE OF CAllFORNTA °71W[1? W)VIER kNSOURCYTS 1XIAW) P.()- BOX 527 PARAMOUMI', (A IXYT23