COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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v. A INNI'RU(TITONS FOR COMPLIUING FORM*B* GENERAL.INNI'RUC110NS- 1. One FORM "B"shall be completed for each tank for all NEW PERMITS PERMIT CTIANGFS, REMOVAI.S and/or any other TANK INFORMATION CTIANGB. 2. This form should be completed by either the PERMII'APPLICANT'or the LOCAL AGENCY UNDERGROUND)TANK INSPECTOR 3. Please type,or print clearly all requested information. 4. Use a hard point writing instrument,you are making,3 copies. 1 bP OF FORM.."MARK ONLY ONE I'&Mi 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DI$A or Facility name where the tank is installed. I. TANK DPSCRIV11ON C OMPLEI-E AL1..IT1?MS-Br 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.2.5,000 or 10,W0 etc.y. H. TANK C:ONTFNPS A. 1. If MOTOR VEIIICH.: FUEL, check box 1 and complete items B& C. 2. If not MOTOR VEHICLE' FUEL, check the appropriate box in section A and complete items B &I). 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. III. TANK COMM'RUC:IION-MARK ONE,'n EM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INI'ERIOR LINING and CORROSION PROT'EC17ION. 2. If OTHER,print in the space provided. IV. PIPING IM70RMAIION 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the I.,EAK Db EC.TION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DMT X'ITON 1. Indicate the LEAK DE:.'T'ECTION system(s) used to comply,with the monitoring requirements for the tank. VL INI`-X)RMATTON ON TANK PERMANE VITM CLC),SED IN PLACE 5 c , 1. FSTIMATrm DATE LAST'USED-MONTI'II/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUIINIANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERI'MA'I7RIAL? Check 'Yes'or'NO'. APPI.IC.AN1'MUST SIGN AND DATT?'DTII?1zC)RM As ImwxTT?D. INSTT ucnON FOR.TIIE LOCAL AGENCIRS 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 State Board to assign the tank number,please leave it blank. IT IS TTI,RI.ST'ONSIIIII:ITY OF'IZIE LOCAL,AGENCY TZIAT INSPECIS111E FAC:II.I1'Y TO VERIFY11111 ACCURACY OF'ITIE INFORMATION. TTIE LOCAL AGI3NCY IS RESPONSIBI I:1 FOR THE COMPLHIION Of'111E "LOCAL AGENCY USB ONLY*INFORMA'11ON BOX AND ICOR FORWARDING ONE FORM"A"AND AS.ocixlm DORM"B"(s)TO-1111E FOLLOWING ADDRESS. STA[E OF CALIFORNIA STA'11?WA'17R RI AURCI?S CONI'ROL BOARD) C/o S.W.I ,--P S& DATA PROCI-SSING C.MNIER P.O.BOX 527 PARAMOUNT',CA 90"M