COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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W�- 1N5rRUC`11ONS FOR(X)MPI1n7NO 1k)WM13' GENERAL YNS7I`RUCI10NS- 1. One FORM"B"shall be completed for each tank for all NEW PERM11S,PFICNITI'CILANGES, REMOVAI—S and/or any other TANK INFORMATION('MANGE. 2 '1 -RMrI'APPLICAN`F or the L(XAL AGFNC-Y UN -ROU Ibis form should be completed by either the PE DERG . NI "TANK INVECI'OR- 3. Please type or print clearly all requested information. 4. Use a jjapd point writing instrument,you are making 3 copies. TOP 017 FORM:"MARK ONLY ONE num L 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. 1. TANK DESCRIVIION-COMP11=7 ALL riliMS-III UNKNOWN-SOSPE(317Y 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.). 11. TANK CX)MI'EMI'S A. 1.If MOTOR VEHICLE MEL,check box I and complete items B& C. 2.If not MO'T'OR 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). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S4. (Chemical Abstract Service number),if box I is NOT checked in A. HL TANK(X)NSTRUC110N-MARK ON13 1r][EM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OFSYSTFM,TANK MATERIAL, INTERIOR IANING and CORROSION PROT1.zCI'ION, 2. If OTHER,print in the space provided. TV. PIPING H4MRMXI1ON 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle,or if OTIIEB,print in space provided. 1 Indicate the LEAK DEUECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK IJ�AKDF'I'VL'17ON 1, Indicate the LEAK DEFEC`1`10N system(s) used to comply with the monitoring requirements for the tank. VL INVI, zA'l )N TANK DERMA '[Y CLOSED IN PLACE I I'D DATE LAST USED-MON7]TI/YEAR(January, 1988 or 01/88). 2. ES-H%1ATE0 QUANTITY of HAZARDOUS SUBSLANCE remaining in the,tank(in Gallons). 3. WASTANK FILLED WITH INEwr MA'IERIAL? Check 'Yes'or'NO'. APM 1� A',;-T MUST SIGN AND DX117,111E TX)RM AS INDICATED. INS'llZUf 71ON FORTHE LOCALAGENCIMIS 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 &-)ard to assign the tank number,please leave it blank. IT IS'1711?RI,-1;V-XNS1M3IXFY OF11112 LOCAL AGEN(7Y,mxr Nspuursnw v'AcmiTYTO VLIRH-.,f THE ACCURALY 01111W INFORMATIOM I OCAL A(;F',N(.Y IS R[NPONSIBLE,FOR TIIE CoMIPLEnON OF THE "LOCAL AGENCY US1-I ONLY" INFORMA410N ROX AND FOR lk)RWARI)ING ONE FORM W AND ASSOCIATED IZORM'IP(s)1`0'111 E'FOI.,LOWING ADI)Rl,,SS, 517VIV OF CAMFORNIA 91WIF,WXIV R RI—SOUR(I?S CON IVOL,BOARD C/O&W.EF—P.S. DA7FA PRO0MING CEIVIT'R P.O.I-X)X 577' PARAMOUNW,CA-%M'!