COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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IN91RUCTIONS FOR COMPI.HTING FORM "B" G14NFRAL INSTRUCTIONS: 1. One FORM "B" shall be completed for each tank for all NEW PFRMTTS, PERMIT CHANGES, REMOVALS and/or any other TANK. INNORMAIION CHANGE. 2. This form should be completed by either the PI3RMCT APPIICANF or the LOCAL AGENCY UNDERGROUND TANK INSPI?CTOR. 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 TTM'" ' 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 1; acility name where the tank is installed. 1. TANK DESCRIPTION - COMPI.i',r17: ALL ITEMS - IF UNKNOWN - SO SPBM-f. A. Indicate owners tank ID # - 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). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). II. TANK CONTWTS A. 1. If MOTOR VEHICLE FUEL, 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 & 1). B. 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 G)NSTRUCTION - MARK ONE 17112A ONLY IN BOX A, I1, C dt. D 1. Check only one item in TYPE OF SYSTEM, 'TANK MNITRIAL, INTERIOR LINING and CORROSION PROTEC110N. 2. If OTHER, print in the space provided. I.V. 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 DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DF1'F.CTION 1. Indicate the LEAK DI:l'ECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PHRMANE7.N'I1,Y C20SED IN PLACE 1. ESTIMATED DAl'E LAST USED - MONTII/YEAR (January, 1988 or 01/88). 2. FSHMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO'. APPLICANT MUST SIGN AND DATE 11IE FORM AS INDICATED. INSTRUCTION FOR 711E E )CAL AGI:NC.IES 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 ()16)739-2421. The facility number must be the same as shown in forry 'A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabct. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS'11113 RESPONSIBII.TI'Y OF 'I71F I.UC'AL AGENCY 11IAT INSPECTS 11IF FAC11.r1 Y 111 VERIFY'171H ACCURACY OF 1111? INFORMATION. '1I1F LOCAL AGF.NC.'Y IS RESTONSIBLF FOR ,nIE C,OMPL1:nION OF'111E "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOC.'EA 19) FORM "B"(s)1.0 TILE FOLIAWING ADDRESS. STA.I1? OF CALIFORNIA STATE WATER R01OURCES CONTROL BOARD C/o S.W.IffutP.S~' - DATA PROCESSING CV1VrHR P.U. BOX 527 PARAMOUNT, CA WM 0 .11 :,., I- � �� I : , ..,: , : 0