COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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INSTRUCITONS FOR COMPL E riNG FORM"B" GENERAL.INSTRUCT IONS: 1. One FORM "B"shall be completed for each tank for all NEW PERMI'VS,PERMIT CIIANGRS, REMOVALS and/or any other TANK INFORMATION CHANGE:. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGI-.NCY UNDERGROUND 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 ONI?I TIDW 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. I. TANK DF_SC:RIPIION-C OMP1.171'E AId.rIT..?.MS-19?UNKNOWN-SO SPE(MI llY A. Indicate owners tank 1D #-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.). 11. TANK CONII'NI5 A. 1. If MOTOR VEHICLI FUEL,,check box I and complete items B K C. 2. If not MOTOR VEHICLE FL'IL,check the appropriate box in section A and complete items B R D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box I 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 CONSIRUCLION-MARK ONE 17I1;M ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION PROTEC110N. 2. If OTHER,print in the space provided. LV. 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 DF.IMC-17ON systems)used to comply with the monitoring requirement for the piping. V. TANK LEAK DE'1'EC nON 1. Indicate the LEAK DE"IICTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANF,NII.Y C:I..OSED IN PLACE 1. ESTIMATED DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBS-FANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WIIT-I INER':I'MAIM.RIAL;? Check 'Yes'or'NO'. APPI1CANi'MUST'SIGN AND DATE'111E 17ORM AS IN)IC:ATED. IN.STRUCMON FOR 111E 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 are predetermined and can be obtained by calling the State Board (916)739-2421.. The facility number must be the same as shown in Conn "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 i7m RF.SPONSII tm-y OI+mm I.ACAI.ACi1?Nc-f'1HAT INSPLcIs niE FACILITY 177 VERIFY nw ACCURACY 0171111;INFORMA7110N. 111E LOCAL AGENCY IS RESPONSIBLE FOR TUE(X)MPI.VI.TON OWITIE? "II)CAL AGENCY USE:ONLY'INFORMAITON BOX AND FOR FORWARDING ONE FORM'A"AND ASSOC I 1770 FORM-Br(s)TO TLIE FOIJAWING ADDRESS. STAIE OF CA11FORNIA NI'AIV,WA713R RESOURCES CONTROL BOARD C/O S.W.E:.I?PS. DATA PROCT;SSING CI:WI'1?R P.O.BOX 527 PARAMOUNT,CA 90—M