COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

Home Browse Search

INSMRU(."170N"S FOR C."OMPIXU INCI IDDM'130 GENERAL ,5�1RUC;ITON : 1. One FORM"B"shall be completed for each tank for all NEW ISI? -S,PERMrr C;IANGI�LS, REMO"V'AI S and/or arra other TANK INFORMNITON CHANGE 2. This form should be completed by either the PERNiI'1' PUCANI"or the IDCAI.A(31:.N, "(JNI)l?R(.3 C)1JNI)"1°rA IK INSPECT)IZ; 3. Please type or print clearly all requested information 4, Use a hard point writing irtstrta;nae nt,you are snaking 3 copies, r0P OF FORM-*MARK ONLY ONE 1717M' 1. Nark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA o#,Itacility name where the tank is installed. 1. rANK DF—S CAVI"O -C.MOLT 113 ALL MNS A 110 UNKNOWN-1,50 SPECIFY A. Indicate owners tank II) M If there is a tank number that is used by the owner to identify the tank(ex.AI37078e3). B. Indicate the name of the company that manufactured the tank(ex.ACM TANK MFG.). C. Indicate the year the tank was installed(ex. 1987), D. Indicate the tank capacity in gallons(ex,2.5,000 or 10,000 etc.) , 19. TANK C; I A, 1. If MOTOR VEHICLE,FUEL,check box 1 and complete items I3 &C. 2.If not MOTOR VFII1CI.,I' F FEL,check the appropriate box in section A and complete items LI &11 E3. Check the appropriate box. C. Check the type of MO`I'C)I2 VEHICLE E"CJEL(if box I is checked in A). D. Print the the€rrical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Set-vice number), if box I is 'SOT checked in A. III. TANK CC) S'1"IZL)(711014«MARK ONE rl'EM ONLY IN BOX A,13,Cd&I) 7. Check only one item in'1"Y I'I_r;OF SYST EM,'I'ANIK MATERIAL,IN7FE tIC)I2 LINI G' and CORROSION I'RO T 13,c°ION. 2. If C7"I'HER,print in the space;provided. . PIPING IMIORMA71TON 1. Circle A if above ground;circle I.I if underground; and circle both if applicable. 2. If UNKNOWN,circle;or if OTHER,print in space provided, 3. Indicate the LEAK IS'E;i'h:CI"ION system(s) used to comply with the monitoring requirement for the piping. V. TANK MAK DITWX717ON 1. Indicate.the TEAK Di,�,C ON systenr(s) used to comply with the monitoring requirements for the tank. VI. FNIX) 'IIC)N ONTANK PE ANEX11M CI..C),SED IN PLACE 1. =MATED D DA , I.A51I USED-MONTH/YEAR(January, 1.988 or 6i*). 2. ESTIMATED QUANrrry of IiA7Al2DOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK E7II,LL0 WI1111 INEXF; ITRIAL:k Check'Yes'or'N0% APP11CANT MU9rS1GN AND I)ATI?"I11E ITC Rif AS . )I a I . .. UCI11C)N FOR 71113 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 arepredetermined and can be obtained by calling the State Board(916)73x1-2421: the facility numbermust be the same as shown ins form "tA". 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. 1T IS TfiE RENTONS1.11111TY OF"I'TIE LOCAL ACTIN,AGINCY T11KF ISI PEEM`111E FAC11< "7`C)VI:; "1"1 11 ACC'URACYOF11IE1pJF0RMJV170N. ITIE IAOCAL AGENCY IS 12I&SPONSIBLE FOR TIIII COMPLU110N C)Ir'T: II *LOCAL AGENCY USE ONLY"INFORMSITON BOX AND ISR R)12 ARSING ONE 1= "A"ANIS AS.SC)C11 IIED I -II"(s)"ID 11113,1k)LIDWING DR S. ,WA11!OF CALHIORNIA S~}:A'I s WAITR 1113SC)1,.712 C°CIhI"IROL,9 IIC)ARD DATA PROCESSING C I? IIIsI2 P.O.BOX 527 PARAMOUNT—,CA 9077-31 w