COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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JNS1.RUC11ONS FOR COMPIJA'1N(;FORM-1.4- GENERAL INSTRUCTIONS: L One FORM "B"shall be completed for each Imik for all NEW PFRMYI'S,Pf:,RMrF CHANGES, RI!',MOVALSand/()r.anV other TANK INFORMA17ON CIIANGF- 1 'Chis form should be completed by either the PERM13'APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK INSPW. 1'OPL 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. 'I'OP OF FORM-*MARK ONLY ONE?n'T?.M-' 1. Mark an (X) in the box next to the item that best describes the reason the form is;being conVieted. 2. Indicate the DRA or Facility name where the tank is installed.' 1. TANK DF-S(3WITON-COMPIEVE ALL r112AS-H?UNKNOWN-SO SPECIFY A. Indicate owners tank 11) # -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). 1). Indicate the tank capacity in gallons(ex.25,(()0 or 10,wo etc.)." I.I. 17ANK CON17Wn' A. L 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 I is checked in A). 0. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service number),if box I is NOT checked in A. III. TANK CONSTPUCHON-MARK ONE n7lm ONLY IN BOX A,D,C&D 1. Check only one item in TYPE OF SYSTEM,TALK MATERIAL,INTERIOR LINING and CORROSION PRO`I'E(TlON. 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 OTHER,print in space provided. 3. Indicate the LEAK D'ETEC11ON system(s) used to comply with the nionitoring requirement for the piping V. TANK LEAK DHIIE CON 1. Indicate the LEAK DETEC'I I[ON syNtem(s) used to comply with the monitoring requirements for,the tank. VL INFORMATION ON TANK PERMANENITY CTOSIED IN PLACIt I. ESTIMATED DATE LAST USED-NION-1-II/YEAR(January, 1,988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOU'S SUBSTANCE remaining in the tank(in Gallons), 1 WAS TANK MIXED WrIll INI:!.RT MATERIAL? Check'Yes'or!No'. APPLICANF MUST SIGN AND DATM111111 FORM AS INDICKITiD. IN,"U'RUC37ON FOR'ITIF 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". 1lie tank number may be assigned by the local agenm 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. YJ TS THE RESPONSIBILM OF 771H LOCAL AGE:N(YT1-IAT INSPIX3S THE FACILITY TO VERIFY 1111i ACCURACY OF 11113 INFORMATION. THE r,-OCAL AGENCY IS RESPONSIBLE 17OR17111 C-OMPIHnON1 Of'-17111 %LO�CAL AGIINC Y,USE ONLY,INFORMATION BOX AND FOR FORWARDING ONE FORM*A'AND ASSOCIATED FORM'B'(9)TO 11113 FOLLOWING ADDR1?--s,& FrA711F,OF CALIFORNIA 91WIE WA'AER RESOLIFT77i t CIJ II OI.,WARD 1SW,71 D/VIA FROC11WiING CE"INUT,"R P.O.BOX 527 PARAMOUN117,CA WM