COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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IN,%'lRUC`I1ONS FOR COMPLVIING FORM'W GENERAL IN917RUCHONS- 1. One FORM "B"shall be completed for each tank for all NEW PFRMTI*S, PERMIT` CIIANGIS, RFMOVAI_Sand: or a1% other TANK INFORMAITON MANGE. 1 'This form should be completed by either the PERMIT APP11CANT'or the LOCAL AGENCY UNDERGROI)ND'I'ANK INSP19CIrOF- 3, Please type or print clearly all requested information. 4. Use a bard point writing instrument, you are making 3 copies. `1X)P OF FORM: 'MARK ONLY ONE 1`111W 1. Mark an (X) in the box next to the item ilia. best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the lank is installed. 1. TANK DI_ RfP`1TON - COMPLHII! All, 1717EMS - IF UNKNOWN -SO SPfX.'fFy A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tanl lea. AB70789). B. Indicate the name of the company that mawi[ac°urcd the tank ".Cml MFG,), C. Indicate the year the tank was installed ((,x.'1987). D. Indicate the tank capacity in gallons (ex. 2-5,000 or 10,000 etc.). IT. TANK CON11.11NI'S A. L If MO'T'OR VF',IIICLF FUEL, check box I and complete items B & C. 2. If not N401'OR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE MET, (if box I 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 I is NOT checked in A. Ill. TANK CONSI'RUC71710N - MARK ONE rI'EM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF'SYSTEM, TANK NCN`I'ERIAL, INTERIOR LINING and CORROSION PRO'I'F(.-,IION. 2. If O'FHER, 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 O'IIIER. print in space provided, 3. Indicate the LEAK DF'IEC'I'ION system(s) used to comply with the monitoring requirement for the piping. V. 'TANK LEAK DE`I*FC711ON 1. Indicate the LEAK DE -I . F,CnON system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENI'LY CLOS1.11) IN PLACE 1. ES1`IMKI'ED DATE IAS'11 USED - NIONTI-Iliyl-AR (January, 19M or 01/88). 2. FSI'IMATE.D QUANI1'FY of IIAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MA'17FRIAL? Check 'Yes'or 'NO'. APPLICANI' MUST" SIGN AND DAIV,11 113 FORM AS INDICN11T ), INSI'RUCIION I`k')R'nIE LOCAL AGENCIES 'I'lic 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. 'I'lie 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". 'I'lie tank number may be assigned by the local agency, however, this nunih.er 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. rr IS THE RESPONSIBIIXI'Y OF ITIE LOCAL AGENCY'MAT INSPECIN171E FACILITY 1Y? VERIFY111E ACCURACY OF 171111 INFORMAITON. 77113 LOCAL AGE.NC`Y IS RESPONSIBIJ. FOR,nIE COMPI_HnON OF IM3 *LOCAL AGE24CY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORMA' AND ASSOCIA110 FORM -Ir(s) 170171E? 17011,OWING ADDRESS. `FA717 OF CALIFORNIA grNI117 WXrER RESOURCES CONTROL BOARD C/o S.W.F_nps. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90773