COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

ENSTItUCLIONS FOR COMPAC, FORM"Ii" • tW GI NFs INS'FRUC.t'IONS: � Ir One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES,S, RE MOVAI:A d/or any other'TANK INFORMATION CHANGE 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGI.NCY UNDERGROUNI)�TANK INSPP.C•I'OLL 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF DORM: "ANRK-O"ONL:I31 E 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 k;arility name where the tank is installed. 1. TANK DES (3OMPLHT[`All,ITEMS-EF 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 10,000 etc.). ' H. 'TANK CONI'FWrS A. 1.11f MOTOR VEHIC1,11, FVFI'-,check b(U 1 and.Zomplete.items B &C. I If not MOTOR VEHICLE FUEL,check the appropriate box in section Ah 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. IIL 'TANK wNsTRUCIION-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 PRO'Iti('I'ION. 2. If OT"IIE R,print in the space provided. IV. PIPING INFORMATLON 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 I MK DEEV{ TION system(s)used to comply with the monitoring requirement for the piping. V. 'TANK LEAK DLIEC1ION „ 1. Indicate the LEAK DI;I I CTION systems) used to corr"ipri with the monitoring requirements for the tank. VI. INFORMN11ON ON TANK PERMANINIZY C I OSED IN PLACES 1. L:STIMATED DATE:IASr USED-MONTII/`i'I:AR(January, 1988 or 01/88). 2. ESTIMATED QUANTrrY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MNIT?RIAL.? Check 'Yes'or'NO'. APPLICANT MUSE'SIGN AND DATE T1Lt;FORM AS INDICATED. INSTRUC'I1ON FOR'IIIE 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 Sta+c Board to assign the tank number,please leave it blank. I'T IS T11E:RFSPONSIBUXI'Y OF THE LOCAL AGENCY 111A1'INSPECIS T'IIE FAC'ILIT'Y TO VERIFY 171I3 ACCURACY OF'17EE INFORMATION. TIIEr LOCAL,AGENCY IS RESPONSIBLE I7OR T1IE COMPI.E:iITON OFTIIE *LOCAL AGENCY USE ONLY"INFORMAIION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM"B"(s)TOT11F.FOII.OWINCi ADDRESS. STATE OF CALIFORNIA j STATE WA1ER RESOUI2,gii C ONII�OL BOA KD C/O S.W.EiE.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723