COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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0 0 INSTRUCTIONS FOR COMPLETING.DORM"B" GENI3RAL..INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERM11T CITANGES, REMOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PBRNlrT 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. TOP OF FORM:'MARK ONLY ONE rnN* 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 DFSCRIPITON-C:OMPI.E1Td All.rl'F.MS-IF 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.A1I70789). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MF(i.). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). II. TANK CONTENTS A. 1. If MOTOR VEHICLE FUEL,check box I and complete items B &C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). I). 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. M. TANK CON91RUCIION-MARK ONE ITEM ONLY IN BOX A,11,C&D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTTIEk,print in the space provided. TV. 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 DETTCIION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DEI'z_'nON 1. Indicate the LEAK DE'I"ECTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMA"IION ON TANK.PERMANI.NI'LY CLOSED IN PLACE 1. ESTIMATED DA'Z'E LAST'USEI)-MONTH/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS'TANK PILLED WTIII INERT'MATT RIAL?Check 'Yes'or'NO'. APPLICANT'MUST SIGN AND DATE THE FORM AS INDIC 11114D. INSTRUCTION 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. I'he 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 um RF.SPONSm=y OF THE TOCAI.AGENCY LILA!'INSPECIS THE FACII.r1'Y TC)VERITY 11IE? ACCURACY OF'IIIE?INFORMA710N. IIIE IOCAL AGENCY IS RESPONSIBLE FOR TRE COMPLETION OF IIIE 'LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED FORM'B'(s)TO HE FOLLOWING ADDRESS. STATE OF CALIFORNIA STAIV WA1.1 R RESOURCUS CONIROL BOARD C/o S.W.E.E?PJs. DATA PROCESSING CINE ER P.O.BOX 527 PARAMOUNT,CA 90723 • w w.Al,.. ....:... .,..., .>. �: ,.. Via;, ^.Yr•� •. .Y-,:; R,.rp r.