COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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s INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS: I One F ;<" .,F„ oial 1, 1) r fr each tank for all NEW PERMITS. PERMIT CHANGES, REMOVALS and/or any C c,r. TANK INF OFtF1AT'ICN GRANGE This frrr hc;a i i he t�)r;i r�t��d 1,y ei ther the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3 Please tv�)Ce or print cledrly a'? requested lnftormmtion. 4 Use-a hard point writing instrument. you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE ITEM" 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 Faviliiy namo where the tank is installed. I . TANK DESCRIPTION -COMPLETE ALL ITEMS - IF UNKNOWN. - SO SPECIFY A. Ir i at. tuner tank 11 u If t':;: 'e is a c:)nl: nurniber that s used by the owner to identify the tank Al ,'i;'H9) B Indicate t:he name of' the company th..t. manufactured the tank. (ex. ACME TANK MFG). C. Indicate the year the tank was lnsi:alled (ex. 1987) D. Indicate the Lank .;ap:;..ity in a? ;;ns (ex 25,000 or 10,000 etc.) II. TANK CONTENTS A. 1. IF M()TOR VFHICL.E FUEL. check box I and complete items B & C. 2. If not MOTOR VEHI(:IF FUEL.. Jheck the al)prial)riate box in section A and complete items B & D. B Check tfr: appropriate tbox. C. Check the type of MOTOR V1HICu (11[:1.. (if' box 1 is checked in A). D Print the chemical name of the hazardouv: substance stored in the tank and the C.A.S.#. (Chemical Abstract. SCr'v1Ct' number). if b;i?x 1 is N01 checked in A. III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D 1. Cheek orly one item in rYP 0 'ySTFM. TANK MATER A1.. INTERIOR LINING and CORROSION PROTECTION. If O HER, print in the spa_e pr'avidect. IV. PIPING INFORMATION 1. Circle A if aboveground circle U if underground, and circle both if applicable. 2. If UNKNOWN circle: or if OTHER, print in space provided 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION I. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED MONIIIiYE..AR (January. 1.988 or 01/88) 2. ESilMATED QUANTITY of HA7A'<.DOUS SUPSTANCE remaining in the tank (in Gallons). ,1,. . WAS TANK FILLED WITH INERT MATERIAL? "'heck 'Yes' or 'NO' APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE 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. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. 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 THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS.