COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

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INS"IRUC'ITONS FOR COMP11rIING FORM*B* GENERAL.INSTRUCIIONS- 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVAI S and/or any other TANK INFORMA770N CIIANGE. 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDIMGROUND TANK INSPECTOR- 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM.*MARK ONLY ONE TItEM" 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the IIIA or]Virility name where the tank is installed. I. 'TANK DPSCRIPITC'YN-CX)MPLum Au.rI.T ms-IIJ 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 C)N`nW1-S A. I. If MOTOR VEHICLE FUEL,, check box 1 and complete items B & C. 2.If not MOTOR VFIIICI,E FUEL,check the appropriate box in section A and complete items B& 1.). 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 CONS[RU(N ION-MARK ONE n-FM ONLY IN BOX A,13,C&I) 1. Check only one item in'TYPE OF SYSTEM,"TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,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 OTHER,print in space provided. 3. Indicate the LEAK DE-I'EM. ON systems) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETI?CI1ON 1. Indicate the LEAK DE':TECTION system(s)used to comply with the monitoring requirements for the tank. VL INFORMATION ON'TANK PERMANI?M11,Y CI OSED IN PLACE 1. ESTIMATED DATE I..ASI'USED-MONTH/YEAR(January, 1988 or OTjeB). 2. ESTIMATED QUANTITY of LIA1'.ARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK F1,I.,Lt-,D WITH INERT MAT,,RIAL? Check 'Yes'or'NO'. APPI.ICAMr MUST SIGN AND DATE 11IE FORM AS INDICATED. INSTRUCITON FOR TIIE L0C AL 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)739-2121, The facility number must be the same as shown iri'•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. rT IS THE RESPONSII3II.TIY OF THE IACAL AGENCY THAT INSPECTS'ITH?FAC:111TY TO VERIFY 71111:; ACCURACY OF'ITIE INIX)RMAIION. TILE I.,OCAL AGENCY IS RESPONSIBLE FOR 1't II?COMPIHIION OF'IIIE *LOCAL AGENCY USE ONLY*INFORMNIION BOX AND FOR FORWARDING ONE FORM'A*AND ASSOCIAII3D FORM'B'(s)TY)'IIIE3 FOLLOWING ADDRESS. STAIE OF CALIFORNIA S1A71T*WATER RESOURCV-S CONTROL BOARD C/O S.W.I?1:Y P.S. DATA PROC'X--SSINti CENTER P.O.BOX 527 PARAMOUNT,CA 90723