COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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IN91'RUCIIONS FOR COMPI..E • FORM "I3" • GENERAL IN,STRUCnONS: t. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMrr CIIANGFS, RF.MOVAIS and/or any other TANK INFORMAIION CHANGE; 2. This form should be completed by either the PIIRMrr APPLICANT or the IOC:AL AGENCY UNDERGROUND TANK INSPLFCTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 'FOP OF FORM: "MARK ONLY ONE ITI14" ` ' L Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the D13A or Facility name where the tank is installed. __ s I. 'TANK DFSCRIPIION - COMPI.LIE ALL. rrEMS - IF UNKNOWN - SO SPECLFY . 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. ACMETANK 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.). 11. 'TANK CONTENTS A. I. If MOTOR VEHICI..E 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 & D, 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 I is NOT checked in A. j III, '.TANK C ONSTRUGTLON - MARK ONE r"? ONLY IN BOX A, I3, C & D 1. Check only one item in 'TYPE OF SYSI'EM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTEC7110N. 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 DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK Df-rl GTION 1. Indicate the LEAK DL;I'E,CTION system(s) used to comply with the monitoring requirements for the tank. VL. INFORMAIION ON TANK PERMANF.NII,Y C'1.C).SI'.fi IN PLACE 1. ESTIMATED I)A'I,, LAST USED - MONTII/YPAR (January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), 3. WAS TANK IILLEI) WITH INERT MATERIAL? Check 'Yes' or 'NO'. APPLICANT MUST SIGN AND DATE 111E FORM AS INDICN1W. IN;STRU(.TION FOR 1111.. IDCAL AGLiNC.'IFS 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 catling 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 TIIE RESPONSISIIIIY OF'IIIE IOC:AL AGENCY 1IIAT INSPECTN 11IE FACILr1Y 1'O VERU -`Y THE ACCURACY OF 111E INFORMATION. 'ITIS IOCAL AGENCY IS RESPONSIBLE FOR'IIIE, COMPLETION OF 1ITE "LOCAL, AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOC IATEI) FORM "Il"(s)1.01ITE FOLLOWING ADDRESS. STATI? OF CALIFORNIA S"rA'.TE WA RF4SOURC;ES C()NI ROL BOARD C/O S.W.F.E P.S. , ... i s DA.rA PROCESSING C EN`I :R P.O. BOX 527 PARAMOUNT, CA 90M