COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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RWMUC'1TONS FOR COMPIMING K)RM % GENERAL INSTRUCTIONS - 1. One FORM "B" shall be completed for each tank for all NEW PfflUMTIN, PERMIT CHANGES, RfWOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPUCANT or the I.DCAL 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. I. 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 DESCRIPTION - COMPIZIE All. ITEMS - EF 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.). A. 1. If MOTOR VEHICLE FUEL, check box 1 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 FUFI, (if box I is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Semice number), if box 1 is NOT checked in A. IIL TANK CONSTRUCTION - MARK ONE ITFM ONLY IN BOX A, A C & D 1. Check only one item in 'TYPE OF SYSTEM, TANK MATERIAL, INFFERIOR 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 O'ITIER, print in space provided. 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECON L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. 1. ESTIMATED DATE LAST USED - MON`I1I/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITI I INERT MATERIAL? Check 'Yes' or 'NO'. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE 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 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 THE RESPONSIBUffff OF ITIE LOCAL AGENCY THAT INSPECTS TI IE FAC111T Y TO VERIFY 11111-7 ACCURACY OF THE INFORMATION. TTIE LOCAL AGENCY IS RFSSPONSIBLH FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND 17OR FORWARDING ONE FORM *W AND ASSOCIATED FORM 'B'(S) TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STA 117 WATER RESOURCES CONTROL BOARD C/o &W.Tul Ps. DATA PRO&ING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 0 #6