COMPLIANCE INFO_1992-2000 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS: l One "B" JW I e Y ;r,,,' t ell' f:,., each tank for, a i 1 NEW PERMITS. PERMIT CHANGES, REMOVALS and/or any other TANK INFORMATION CHANGE. This form °'h0iJ1d be cOmplotod Iy either the PERMIT APPLICANTar the LOCAL AGENCY UNDERGROUND TANK - INSPECTOR. .I Pleas, t,<,(, or print. Clearly a?1 r('quested information, 4 Use a hard point writing instrument...you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE ITEM" I 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. I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Irr a':. w ;'r'S tani If tf,: e is a ank numb r that is used by the owner to identify the tank B Indicate the name of the company that. marufa��tured the tank (ex. ACME TANK MFG). (; IndlCatp a.`ie year t1'. t,ank ter" ,rs' -1 ?ed (ex. 19B'). ri Indicate the tank cape i 'r -.?',,;is (ex_ 25.000 or 10.000 etc. II. TANK CONTENTS A. 1, II MCOTOR VE.HICE FUR!_. check box 1 and com;ilrte items B & C. 2. If not MOTOR VE!jTC' 1.1EL, check tho appropriate box in section A and complete items B & D. B Check this al:proprialto box C. Check ter(, type of M(?fOR V[HICIE. 1U[I... (if box I is checked in A). D. Print the chemical rname of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstr:iA. `ervice nunber ). if box I is NOI checked in A. III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A. B. C & D 1.. Check or)ly one item in TYhE 15F SYSTEM TANK MATFRIAi.., INTERIOR LINING and CORROSION PROTECTION. 2. If +i;Ht R. pI'lnt in tli« '11;�:.e f?i-o'v'ide.d. IV. PIPING INFORMATION 1. Circle A if above ground circle U if underground. and circle bath if applicable. 2. If UNKNOWN circle. or if OTHER, print in space provided 3. Indicate the I-EAK 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 ESTIMA:`::D DATE LAST USED - MONIH/YE::.A.R- (January. 1988 or 01/88) 2.. EST �';' :U QUOS"JT I T Y cf HAZ:I<.DC;IiS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MAI :.R.IAL'? Check '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.