COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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,..� ..-ri .,. ..t,.. ... ', ";gin:.-. r.?:e,:.y.. •..........:... ;ih..�'` ,r"<"vl,;�'*, i,�. dkk'a't, '°ta� s rte..- o -..a:. .,� A. m, INSTRUCTIONS FOR COMPLETING FORM"B" GENERAL INST"RUCTTON& 1. One FORM"B"shall be completed for each"tank for all NEW PERMITS PHIVAU CHANGES, REMOVALS and/or any other TANK INFORMATION CHANGE 2. This form should be completed by either the PERMW APPIXANrr'the LOCAL AGENCY UNDERGROUND TANK. 'ECIOR. 3. Please type or print clearly all requested information, 4. Use a hard point writing instrument,you are,making 3 p { TOP OF FORM:"MARK ONLY ONE rltrd4l" # I. i 0mW*X;AerWext to the item that best describes the reason the form is being completed. 2 19gicT t or Facility name where the tank is installed, " ' • . L TANK DFSCRIPT &-COM?IZffl ALL rT S-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 AB70789). N B. Indicate the name of the company that manufactured the"t (ex.ACME TANK MFG.). G Indicate the year the tank was installed (ex."1967). D. Indicate the tar&xapacity in gallons(ex.25X0 or 10,000 etc.). II . TPN itt�'V �AaJ1`t 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 FUEL(if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the ternk and lite C A:S#t.(Chemical Abstract Se?Wce number),if box 1 is NOT checked in A. In, TANK CONSTRUCTION UCTION-MARK ONE rrEM ONLY IN BOX A,B,C`&D 1 Check only'one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. 4. 2. 1f OTHER,print in the space provided. FV PIPING INFORMATION d . 1 , 1, Circle A ifabove ground;circle U if underground;and circle both if applicable. - 2. If UNKNOWN,circle;or if OTHER,print*in sp#ce provided. 3. Indicate the LEAK DE EC11ON system(s)used mply with the monitoring requirement for the piping. TANK I YAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the nton, wy g requirements for the tank. VL INFORMATION ON TANK PER*ANF.NT7.Y CLOSED IN PLACE .3 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January,1986 or 01/88); 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or'NO'. N. APPLICANT MUST SIGN AND DATA TIIE FORM AS INDICATED. , 9(� INSTRUCTION FOR THE IAC,AL AGENCIES ie state nndr�.rgraund storage tank identification number is cotnpased of the two digit county number,the three digit jurisdiction number,the six igit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by lalling the State Board(915)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 REWNSIBELM OF THE LOCAL AGENCY THAT ,S TIM FAC'fI.rTY TO VERIFY THE: ACCURACY OF THE INFORMA11ON LOCAL AGENCY IS RESPONSIBLE FOR Ti IE COMPLEITON OF THE ' "LOCAL AGENCY USE O X AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED TOJPN THE G l RV�" STATE GU1F0 "i11 . dpi %< e STATE WATER RESOURCES CONTROL BOARD C/O S.W.E"E & sf DATA PROCESSING C Pffl pol N c 9f13 8 a ` a t .n.u_u.�.. y� >�LL •+.i.e._._ �....`.__. ...._.:_ .F..d'•:.a ..a..l J:a,LfineisFr�_.�. ..... �e7',^4'.. :':»'.'� � ..