COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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INSIRUCITONS FOR COMPLFIING FORM'B' GENERAL INSTRUC71ON& 1. One FORI4IM "B"shall be completed for each tank for all NEW PERMITS,PERWT CIIANGI,1, REMOVALS and/or any other TANK INFORMATION CIIANGF 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL 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. TOP OF FORM:'MARK ONLY ONE MW' 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-C:OMPIITIII All,1717IMS-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). 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.). IL TANK CONTFNI S A. 1. If MOTOR VEEEICL,E FUEL,,check box 1 and complete items B R 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 tank and the C.A.S.#. (Chemical Abstract Service number), if box 1.is NOT checked in A. M. TANK CONSTRUCTION-MARK ONE PIIN ONLY IN BOX A,11,C&D 1. Check only one item in"[YPE Of'SYS'T'EM,'TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMA710N I. 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 DI`I`ECTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DE:Tf?CTTON 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VI. INIIORMA11ON ON TANK PERMANFW11,Y CLOSED IN PLACE I. ESTIN4ATED DATE LAST USED-MONTIIJYEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLEL)WITH INERT MATERIAL?Check'Yes'or'NO'. APPLICANT MUSC SIGN AND DATE'1T P FORM AS INDIC.A7.I?D. INSTRUCTION FOR 111E LOCAL.AGFNCIFS 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 RESPONSIBILITY OF 171I3 LOCAL,AGENCY THAT INSPECIS 11111 FACILITY TO VERII'Y'111E ACCURACY OF 1IIF INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 1TILI COMPLUITON OF TIIE 'LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE 17ORM'A'AND ASS0C IA'II?D FORM'B'(s)TO THE FOLLOWING ADDRESS. STA1E OF CALIFORNIA STt1IT.WAIT RFSOURCFS CONTROL BOARD C/O S.W.L?I?PS. DATA PROCI::SSING C7W.TER P.O.BOX 527 PARAMOUNT,CA 90723