COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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INSa'TEC.T.T0'ICINS FOIA..COMPI.F:T.I'fNG )R 'Ir GENERAL IN'SrRUCTION& 1. One FORM "B" sba l be completed for each tank for all NEW E Y,IAE 11'CTIANCIF?S, REMOVAI.S and/or any other TANK.IN CJI `J7ON CSI NGF 2. This form should be completed by either the PI3RMr1'APP11CANFor the LOCAL AGIINCY TIN TL?RGRO 1N1 ' INSPEC17PRL 3, Please type,err print clearly all requested information. 4, Use a hard point writing instrument,you are making 3 copies. TOP OF I^t)RM- 'MARK.ONL `til l?TIIk L Mark an (X)in the;box next to the item that best describes the reason the form is being completed. 2. Indicate the IA3A or Facility name where the tank is installed. L TANS DF-SC:RIV1'T(3 -compizim A.L.nFms-IF UNKNOWN®SO SPWIIT € 4 A. Indicate owners tank ID -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 lank(ex.ACME'I"ANK MFG.). C. Indicate the year the tank was installed(ex. 1987). IT. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 ct .): H. TANK CON11WINy A. 1. If MOTOR VEHICLE FUEL, check box 1 and complete items E3&C. 2.If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B&1). B. ('heck the appropriate box. C. Check the type of MOTOR VEHICLE F UE.1,(if box 1 is checked in A). ET. Print the chemical name of the hazardous substance stared in the tank and the C".A.S4.(Chemical Abstract Service nutnbe<r),if box 1 is NC:T checked in.A. III. TANK CCINS''RUCI7f3N T MARK ONE M.24.ONLY IN BOX A,13,Cr&1) 1. Check only one item in TYPE OF SYS:I` -M,TAMC MA`I"IiJUA3., INFIEii TOR,LINING and CORROSION PROTEC110N. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION 1. Circle A if above ground;circle U if underground,and circle bath if applicable, 2. If UNKNOWN,circle;or if OTHER,print in space provided. 3. Indicate the ht:?AK IJLTEC`T.T.O V system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK ITIr1'EaV-11(3N 6 � n ;1. Indicate the LEA SI TE ION system(s) used to comply with the monitoring requirements for the tank. VI. INF(1 `FION ON TAMC PERMANENMY CLOSED IN I"I (M 1. 0STIi A'I"I:.D DATE[AS']`USED-rvtC)llITI/I R(January; 1988. or 01/8€1). 2. EFFFISIM'E.D QUAN117ITY of HAZARDOUS SUDSTANCE remaining in the tank(in(.Gallons). 3. WAS TANK F11.11M WITH IM,"It'1 173RAL,',a Check'Yes'or'NO'. APHICAN1711 U917 SIGN AND 13A1117TIE IURM AS M)KWITID. IN>.. UCI7ON FOR'III LOCAL AGY NC_"IIT-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. The county and jurisdiction numbers are predetermined and can be obtained by calling the*Mate Board. (916)739-7421, 'ne 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. ri,Is`1°1113 RmmNsnurry owrim IX)CAL AGINCY 111K.I"INSF ..I's"11113 FA(I.IX17Y M VERWY 11111, ACCURA0f 01 "I'IIE IbIFOR A`170N. 77111 LOCAL AGENCY IS R11-SPONSM1,11 FOR` TIE COMP11filON 017°I1 "IDC-Al,AGENCY USE ONLY' . ) MA'110N BOX AND FOR FOR 1)IN(3 ONE FOR 'A'AND Aw )C . .,I7 FORM-B-(s)TO 1711.MLLOWING ADDRESS. STATE?OF CAI IIORNIA n" IATA PROC HSSSIN(a CI I"i:EC P.O.BOX 527 ISA OU I',CA'.