COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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INS`I'RUC1IONS MR COMPLIT17NO FORM *Ir GENEMAL INSIRUCI K)N& 1. One FORNI-1 "B" shall be completed for cacia tank for all NF,W PFANITI-S, PERmn, CHANGES, RFMOVAI.S.and `or an", other "TANK INFORMA11ON CHANGE, 2. This form should be completed by either lie PERMIT APPI1CANC,)r the LOCAL AGENCY UNDERGROUND TANK INSPECIDR. 3. Please type or print. t, clearly all requested information. 4. Use a hard point writing instrument, you ire -making 3 copies. TOP OF FORM: *MARK ONLY ONE ITEM* 1. Mark an (X) in the box next to the item tlw.t best dc%cribes the reason the form is being completed. 2. Indicate the DBA or Facility name where 1`:!e tank is installed. 1. TANK DESCRIPTION - comw.urp, Au. rarms- UrIONKNOWN - SO SI`FAAFY A. Indicate owners tank 11.) # - If there is o ,umber that is w.r.,,d >y !")e owner to identify the tank (ex. AR770789). B. Indicate the name of the company that.n l.urcd the tank-. "IF TANK C. Indicate, f?tc vcar the tank was installed r '), D. Indicate the tank capacity in gallons (tx, ,?- trVW etc IL TANK CON11.11NI'S A. 1. If MC.Y.I'OR VFIIlCLF FUEL, check box I and complete items B & C. 2. If not MOTOR VF411CLE FUEL, check the appropriate box in section A and complete items B & 1). B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box I is checked in A), 1), Print the chemical name of the hazardous substance stored in the tank and the C.A.S*. (Chemical Abstract Scr�icc number), if. box I is NOT checked in A. 111. TANK CON9fRUCITON - MARK ONE MW ONLY IN BOX A, 14, C & 1) 1. Check only one item in TYPE OF SYSTEM, TANK MWVFERIAL, INTERIOR LINING and CORROSION PROTFCIJON, 2. If O'ITIER, 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 DETEMION system(s) used to comply with the monitoring requirement for the piping. V. TANK LE AK DiiTEC-HON 1. Indicate the LI.,!AK DETECTION system(s) used to comply with the monitoring requirements for the tank, VI. INFORM/VIION ON TANK PERMANUNITY CIAMSED IN PLACE 1. ESTIMATED DA11, IAS1'USED - MON'17111YEXR (January, 1998 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WrYll INERT NLIVI'l-RIAL? Check *Yes' or `NO'. APPLICANT MUST` SIGN AND I)XIM1,111; FORM AS INDICATEI). IMSTRUC11ON FOR TIm LOCAL AGFNCIES 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. C` lr.I'IS UIE RF-SP0NSIBH.rI'Y OF'ITIE LOCAL AGENCY '11IAT INSPECTS FAC-llyff TO VERIFY TIIE AccuRAcycill-nmINFORMA7110N. nlEIX)CAI.AGI?N('YISRFSPONSIBLT-'I?OR'I'Ifl!COMPLSIIONOF'Iiil,' *IMAL AGINCY USE ONLY* INFORMNI'ION BOX AND FOR FORWARDING ONE FORM "A' AND ASSOCINIT'D FORM *W(s)TO1111; FOIJOWING ADDRESS. STAID OF CALIFORNIA STATE WATER RUS )uRcEs CONTROL BOARD C/o smx.E.P.& DATA PROCESSING CWILIR P.O. BOX 527 PARAMOUNT, CA 9VM,