COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

Home Browse Search

"4S-MUCIIONS FOR COMPLFIING FORM 'B" GENERAL INSTRUCTIONS: 1. One FORM "Bshall be completed for each t,,mk for all NEW PE.RWIN, PERMIT CIIANGUS, RFMOVAI-Sand/Or �zPIV other TANK INFORMNITON CHANGE 1 This form should be completed by either the PERMIT APPI.ICANI'or the LOCAL AGENCY UNDERGROUND TA 1NSP1CI7OF- 1 Please type or print clearly all requested information. 4. Use a bard point writing instrument, you are making 3 copies. 'I`OP 017 FORM: "MARK ONLY ONE T11iW 1. Mark an (X) in the box next to the item that lest describes the reason the form is being completed. 2. Indicate the D13A or Facility name where the lank is installed. I. TANK DF-SCRIVIION - COMPIX,113 ALL nTMS - If, UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. A1170789). B. Indicate the name of the company that mariCactured The tank (c,,, ':C,/ETANK MFG.), C. Indicate the year the tank was, installed ((.x. '.987). D. Indicate the tank capacity in gallons (ex. 25,M or 10,000 etc.). 11. TANK (X)NI1.W1`% A. 1. If MOTOR VF"HICLI.- FUEL, check box I and complete items B & C. 2. If not MOTOR 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 VE.11ICLE FUFL (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. M. TANK CONSTRUCTION - MARK ONE rtFm ONLY IN wx A, B, c & D 1. Check only one item in TYPE OFSYSTEM, TANK MA'T'ERIAL, INFERIOR 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. 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DVI"ECTION 1. Indicate the LEAK Dj-,, fECI`lON system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENI'LY CLOSED IN PIACI? 1. ES'llMNI'ED, DATE LAST USED - MON*I-II/YI-AR (January, 1988 or 01/88). 2. ESTIMATED QUANTI'T'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED Wrl'll INERT MATERIA" Check 'Yes'or NO'. APPLICANI' MUST SIGN AND DA`I`E'I1tF- FORM AS INDICNI11), 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)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. IT IS THE RP-SPONSIBHJr.rY OF 1111! LOCAL AGENCY 'Ium, INSPECTS 'TILE FACILITY To VERIFY nut ACCURACY OF 11111 INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 'ITIS COMPLETION OF THE *LOCAL AGENCY USE ONLY* INFORMATION BOX AND IIOR FORWARDING ONE FORM *A* AND ASSOCIATED FORM -1r(s)TO THE FOLLOWING ADDRESS. STA IT? OF CALIFORNIA STMT -1 WA717ER RNSOURCES CONI'ROL BOARD C/o S.W.F-F-P.S. DATA PROCTtSSING, CIWFER P.O. BOX 527 PARAMOUNF, CA 90723