COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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INSFRUCTIONS FOR COMPLETING FORM*B* GENERAL IN iT'R3.1t 1'at 3N�i: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any other'TANK INFORMATION CHANCA 2. This form should be completed by either the PERMIT APPLICANT or the IACAL,AGENCY UNDERGROUND TANK INSPECIUR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. 'I'OP OF FORM:*MARK ONLY ONI?rIEM- 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. L TANK DESCR1VnON-COME LUL,ALL r111MS-IF UNKNOWN-SO SPECIFY A. Indicate owners tank Ila #-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.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.). IL TANK CONI7?N'TS A. 1. If MOTOR VEHICLE FUEL,check box I and complete items B& C. 2. If not MOTOR VE111CLE FUEL,check the appropriate box in section A and complete items B & 1?. B. Check the appropriate box. C. Check the type of MOTOR VEHICI.,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 I is NOT checked in A. III. TANK(Y)N91'RUCIION-MARK ONE ITEM ONLY IN BOX A,B,C&D 1.. Check only one item in TYPE OF SYS'T'EM,TANK MATERIAL, INTERIOR I.,INING and CORROSION PROT'ECI'ION. 2. If OTIIER,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 UNY-NOWN,circle; or if OTHER,print in space provided, 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK I.I:;.AK DEI13C110N 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMNIION ON TANK PERMANENI'LY C:I,OSED IN PLACE 1. ESTIMATED DATE LAST USED-MI ON111/YEAR(January, 1988 or 01/88). 2 ESTIMA'lTD QUANTITY of IIA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WII1I EVERT NvivrERIA[,? Check'Yes'or'NO'. APPLICANT MUSTSIGN AND DATI?'111!3 FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGINC IES The state underground storage tank identification number is composed of the two digit county number, the thl ee 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 State Board to assign the tank number,please leave it blank. rl'IS T1-IE?RESPONSIBUXI'Y OFTHE HE LOCAL.AGENCY 1E1iff INSPE THE FACJI rlY T)VE?RIFY TILE ACCURAC."Y OF TUE INFORMATION. THE LOCAL AGENCY IS RFST'ONSIBLE FOR TME COMPLETION 017,111H •LOCAL,AGENCY USE ONI.X*INFORMATION BOX AND FOR FORWARDING ONE FORM-A*AND ASSOCIATED FORM-B-(s)TO'TTTE FOLLOWING ADDRESS, STATE OF CALIFORNIA STALE WATER RESOURCES CONI"ROL BOARD C/O S.W.I?E P.S. DATA PROCESSING CMWII-IR P.O.BOX 527 PARAMOUNT,CA WM,