COMPLIANCE INFO_1986-1993 - Laserfiche WebLink

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t INSI'RUCIIONS FOR COMPIZ? TNG FORM"B" GENE RAI.INS RUCITONS- i. One FOR'LA"B" shall be completed for each tank for all NEW PERMITS,PERMIT OVANGI:?S, REMOVAL.�S anchor any other TANK INF ORMA1.1ON CIIANGE. 2. This form should be completed by either the PERMrT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hares point writing instrument,you are making 3 copies. TOP OF FORM: "MARK ONLY ONE IIT:?M" L 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 DF_SC RIP'ITON-C'OMPLUIT:ALI.riT9%S-W UNKNOWN-SO SPECIFY 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 10,010 etc.). H. "BANK C.ON 11W S A. 1, If MOTOR VEIIICLE3 FUEL,check box 1 and complete items B &C. 2. If not MOTOR VEIIICIA"FUEL,check the appropriate box in section A and complete items B & D. R Check the appropriate box. C. Check the type of MOTOR VEi1IICL E,,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. 111. 'LANK C".ONS'rRUCnON-MARK ONE ITEM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, INIURIOR LINING and CORROSION PRO`I14"CI'ION. 2. If OTIIIR,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 OTIIER,print in space provided. 3. Indicate the LEAK DE'>'I`I�CTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DET13CITON L Indicate the LAK DE'11 CTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANI:WIl Y C IA)SED IN PLACE 1. ESTIMATED DATE LAST USED-MONTI-I/Y11AR(January, 1.988 or 01/88). 2. E5.11MATI3D QUANTI'T'Y of IIA%ARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INFRT MATERIAL? Check'Yes'or'NO'. APPLIC AN.I'MUST SIGN AND DA 1`I?'I1IE FORM AS INDICATED. INS`MUC ][QN FOR'17113,LOCAL AGENCIES The state underground storage tank identification numker 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 Sta+e Board to assign the tank number,please leave it blank. rI'IS 171E RESPONSIBIL TTY OF 11111 IACAL AGENCY THAT INSPIM TIIE FACIIXI'Y TO VERIFY'ITIS ACCURACY OF'I1IE INFORMA7110N. THE LOCAL AGtNCY IS RESPONSIBI.Z;FOR TILE COMPId311ON OF 111E "LOCAL AGENCY USE ONLY"INFORMAITON BOX AND FOR FORWARDING ONE FORM'A"AND AS,SOCINI'ED FORM"B"(s)TO-111E FOLIA)WING ADDRESS. STA111 OF CALIFORNIA SUVIE WYVIER RI?SOURCS C'ONITLOL BOARD C/O S.W.E.I?P.S. DATA PROCESSING C l.WrER P.O.BOX 527 PARAMOUNT',CA 90723