COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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• TNSIRUCI'IONS FOR COMPLITLNG FORM"B" GENERAL INSTRUCnONS 1. One FORM"B"shall be completed for each tank for all NEW PERMTIS,PERMrr CIIANGES, REMOVALS and/or any other TANK INFORMATION CHANGE 2. This form should be completed by either the PERMIT APPLICANT'or the i..00',AL AGENCY UNDERGROUND'TANK INSPECFOF- 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 I B4' 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. 1. TANK DESCRIPTION-COMPIZIM ALL rITNS-W 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.). 11. TANK CON2FNI'S A. 1.. If MOTOR VEI11CLE 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 I is checked in A). D. 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. III. TANK CONST'RUCITON-MARK ONE ITEM ONLY IN BOX A,13,C_&D 1. Check only one item in TYPE OF SYSTE_%I,'TANK MATERIAL, I'N'TERIOR LINING and CORROSION PROT'F..,CDON. 2. If OTIIEFR 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 LF..AK DE,rBC11ON system(s)used to comply with the monitoring requirement for the piping. V. TANK LI?AK DLIT3CI'ION 1. Indicate the LFAK D1rIT:CTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMA'IION ON TANK PERMANENTLY CLOSED IN PIACE 1. ESTIMATED DATE LAST'USED-MONTII/YEAR(January, 1988 or 01/88). 2. FSTIMATED QUANTITY of IIATARDOUS SUBS-TANCE remaining in the tank (in Gallons). 3. WAS TANK TILLED WTITI INERT MATERIAL? Check'Yes'or'NO'. APPIICANr MUST'SIGN AND DATE11-I13.FORM AS INDICA170. LN.SIRUCITON FOR MIE LOCAL AGENCIFS- 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 TILE RFSPONSIBLIZ17Y OF TIIE LOCAL AGFNCY T IUVr INSPECTS TIIE FACILITY TO VERIFY THE ACCURACY OF T9IU INFO RMAITON. 'IIIE LOCAL AGENCY IS RUSPONSIBL F FOR T1 IE C:OMPLI?I.ION OF TT IE *LOCM.AGENCY USE ONLY'INFORMATTON BOX AND FOR FORWARDING ONE FORM A"AND ASSOC IA'I'f?,D FORM'W(s)TO 711E FOLLOWING ADDRESS. ST'ATU OF CAI.,LFORNIA ,SI'A'M?WNI.T:iR RFSOURCFS CONTROL BOARD C/o S.W.I;LIPS. DATA PROCESSING CENIER P.O.BOX 527 PARAMOUNT,CA 90M ,,..,a,,... R„_.:.. yid ,. ylp'4+�y r,, ::•x�tsa",..RA,- ^fi,,, .+1;'b _