COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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INSIRUCIIONS FOR C:OMPL I1NG 17ORM"B" GENERAL INSIRUC'11ON& 1. One FORM "B"shall be completed for each tank for all NEW PERMI71N,PTRMCI'CHANGES, REMOVAIS and/or any otherTANK INFORMATION C:IIANGE. 2. This form should be completed by either the PERMI'C APPLICANTor the LOCAL AGENCY UNDERGROUND TANK INSPE;.CFOR. 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'llW 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the D13A or Facility name where the tank is installed. 1. 'LANK DE:SCRIV11ON-C OMPLE`173 All,nFMS-W UNKNOWN-SO SPMIII?Y 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.2.5,000 or 10,000 etc.). H. TANK CANITWI:S A. I. If MOTOR VEHIC'1.13 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 &1). 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.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK CONS IMU(LION-MARK ONE n-FM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL.,1NIERIOR LINING and CORROSION PRO"I"f3CI'ION. 2. If OTHER,print in the space provided. IV. PIPING INFORMA7EION 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 I)E"1'ECTION sy,Iem(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DEWX'IION 1. Indicate the LEAK DETECTION systems)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENI1 Y CLOSED IN PLACE 1. ESTIMATl i) DATE IASL'USED -MO1NZI7I/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUI3STANCE remaining in the tank(in Gallons). 3. WAS TANK F111FJ)WITH INF1 I MA'fT?RIAf.? Check'Yes'or'NO'. APPLIC:AN17 MUST SIGN AND DATE'I'TIE DORM AS INDLCwrED. INSTRUC:nON FOR THE I..00AL 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. I 'IS THE RFSPONSI.BIIffff OF"IIID LOCAL,AGENCY THKI LNSPECCN 111E FAC:11,L"1'Y TO VERIFY'1'I1T? ACCURACY OF'L1IE INFORMATION. 1I1H I.,OCAL AGENCY IS RESPONSIBLE FOR TLIE COMPIJ I1ON OF'171E "IXW—AL.AGENCY USE ONLY"INPORMALION BOX AND FOR FORWARDING ONE FORM"A"AND AS;SOCINIED FORM"B"(s)TY)'I1I:1?FOLLOWING ADDRESS. ST'AIE OF CALIFORNIA STA'IT WATI3R RI�s()URCFN("C)N1 ROL BOARD C/o SWJ itr"& DATA PROCESSING C EIVI13R P.O.BOX 527 PARAMOUNT,CA 9VM