COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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INSTRUCIIONS FOR COMPLETING I 'B' • GI;NERAI,INSTI RUCTION& 1. One FORM"B`shall be completed for each tank for all NEW P1HRMITS,PERMrr C liANGES, REMOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMTC APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK INSPECIDR 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'II i" 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. I. TANK DF.SC:RIVI'ION-C OMPI.I.3TE ALL PIVMS-IF UNKNOWN-So SPECIFY A. Indicate owners tank II)# -If there is a tank number that is used by the owner to identity 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. 11187). D. Indicate the tank capacity in gallons(ex.25,(W or 10,OW etc.). H. TANK CONTENTS A. 1.If MOTOR VEHICLE 1,UE:'sL,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. & 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 CONSTRUCTION-MARK ONE 1'I1?M ONLY IN BOX A,13,C&D I. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,, INTERIOR LINING and CORROSION PROTECITON. 2. If OTEiER,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 OTIIEK print in space provided. 3. Indicate the LEAK DE`1 C'I'ION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK I)I?I13C110N 1. Indicate the LEAK DETE(711ON systern(s) used to comply with the monitoring requirements for the tank. VI. -INFORMATION ON TANK PERMANEf rII..Y CLOSE)IN PLACE is ESTIMATED DATE..,I.,AST USED MONTII/YEAR(January, 1988 or 61/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE:remaining in the tank(in Gallons). 3. WAS TANK FILLED WZI'LI INERT MXFERIAI ? Check'Yes'or'NO'. APPIICANr MUST SIGN AND DATE 1111?FORM AS INDIC NIM. INSTRUCTION FOR 111E LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county.number, thethree 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. 'I'he 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. Irl,IS THE RFSPONSIBB XrY Otr THE I O AL AGI NCY THAT INSPECTS 111E FAC ILPTY'1)VERITY TIII? ACCURACY OF 11117 INFORMATION. 71][B L(X:AL AGENCY IS RESPONSIBLE FOR I1IE COMPII:TION OF I11E —LOCAL AGENCY USE ONLY"INF)RMAIION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOC3A113D FORM'B'(s)TO 111E FOLLOWING ADDRESS. STA:11?OF CALIFORNIA STATE WA'11?R RESOURCES CONI1tOL BOARD C/O S.WX-E.P.& DATA PROC.I ING CEN` 3R P.O.BOX 327 PARAMOUN'r,CA 90723