COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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INSTRUCT'IONS FOR C'OMPI.VnNG I "B" GENERAL IN,SIRUCIIONS. 1. One FORM"B"shalt be completed for each tank for all NEW PERMI I5,PERMrr(3-IA.NGI?'S, REMOVAI S and/or any other TANK INPORMNIION 0IANGE. 2. This form should be completed by either the PERMTr APPUCANI7 err the LOCAL.AGENCY UNDERGROUND TANK INST., .7OR. 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 ONES TIEm- 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 DFSCRIP 1ON-COMPLI T1?ALL TIT?,MS-IIr UNKNOWN-So SPECIFY A. Indicate owners tank 1.13#-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). I). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). It. TANK CAN11xN`rS A. 1. If MOTOR VFIilCLF FUEL,check box 1 and complete items B & C. 2. If not MOTOR V11I1CLE FUE;T,,check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUJI,(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.#.(ChemicalAbstractService number), if box I is NO'T checked in A. III. TANK CONSTRUCTION-MARK ONI:mw ONLY IN BOX A,B,C&D 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,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 OTHER print in space provided. 3. Indicate the LEAK DE113147FION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DM77CI'ION 1. Indicate the LEAK DTA CE(TDOiN system(s) used to comply with the monitoring requirements for the tank. VI. INFORMAIION ON TANK PE.RMANFNII,Y CLOSED IN PLACE? 1. "FS'[IMATED DA1E LAST USED-MON°ITI/YIsAR(January, 1988 or 01/88). 2. 1STIMA7I'F..,D QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS'TANK PILLED WITH INERT"MAT`ERIAI.? Check'Yes' or'NO'. APPLICANT MUST SIGN AND DAtV 111E FORM AS INDICNIED. INSTRUCZION FOR 111E LOCAL.AGENC1F-4 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. `Fhe 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. Tr IS THE RF.SPONSEBHXIY OP THI3 LO(: AL AGFM.Y THA17 INSPECCS 11IE FACILITY TO VERIIY TIIE ACCU C"X OF THS?INFORMA71ON. 711E IAC:AL AGF,N(,Y IS RESPONSIBI:E FOR 111E COMPIHnON OF 111E 'LOCAL AGENCY USE ONLY"INFORMARON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC3AI'ED PO "B"(s)-10'I71F FOLLOWING ADDRESS. 9FA:M?OF C.ALII'ORNIA SE'ATE WAI1?R RESOURCES CONTROL BOARD C/O S.W.E.E.P& DATA PROCESSING CTNITR P.O.BOX 527 PARAMOUNT,CA 91TT23