COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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TN 1"RUCI3ONS FOR CC_&MI'l.l I G FORM "W GENERAL IN>`s'FRUCI1ONS. 1, One FOR' 1 "13"sha!1 be completed for each tank for all NEWPERMITS,PERMIT CIIANC,I?S, REMOVALS and/or any other'FANK INF ORMN11ON CHANGI? 2. This form should be completed by either the PFRMI'1`APPI.XAN'T or the LOCAL,AGENCY UNDERGROUND"PANIC ( INSPL$-�C FOR. 3. Please type or print clearly all requested information. " 4. Use a hard point writing instrument,you are making 3 copies. I O1'OF FORM. 'MARK ONLY ONE,T113M' 4.. Mark an t" ) in Inc tour: next to the it,:n-; hat best describes tr. .c<aas n the form is beicompleted. 2. Indicate t'l(� 1)BA or facility name w1.,_: the tank is installcF' 1. TANK OIAS(.'RIP'I1ON-(C)MPLJTJT ALL.HEM., IF UNKNOWN- °a11l:.(1FY A. Indicate covners tank 11)# - If there'i:>a tank number that is -.;cJ;ay the owner to identify the tank (ex.A1370789). B. Indicate t''±e name of the company tha rte--nufacturcd the tank :..ACME TANK MFG). C. Indicate t'.,:. year the tank was installed ' x. 1987). T), Indicate the tank capacity in gallons (ey r(M or I0#)0 etc.). 11. TANK(X.)NITNIN A. 1. If MO'T'OR VEIIICH FUEL,check box'I and complete items 13& C. 2. If not MOTOR Vk.1TlCI.,E FULL, check the appropriate box in section A and complete items B&D. 13. Check the appropriate box. C. Check the type of MOTOR V EHICI I FUEL(if box I is checked in A). 1). Print the chemical name of the hazardous substance stored in the tank and the (,A.S.#. (Chemical Abstract Service number), if box I is NOT checked in A. 111. 'TANK CONSIRUC'I`ION-MARK ONE HEM ONLY IN BOX A, 13,C&1) L Check onty one item in TYPE OF SYSrf,*,M,TANK MA"T"T3RIAL, IN`n-.1RIOR 1.INING and Co RROSION PRO'1"1iC11ON. 2. If O'T'TIER,print in the space provided. IV. PIPING INFORMATION 1. Circle A if above ground; circle U it underground; and circle both if applicable. 2. If UNKNOWN,circle or if 01.111313,print in space provided. 1 Indicate the LEAK 1)I'IEC IION systero(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK 1)L;llX'11ON L Indicate the LEAK DE"FECI'1ON system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PE7RMANI. H Y CLOSED IN PLACE 1. FS"T1MATED DATE'LAST US1,D-MON'IIIJYI:AR(January, 1%8 or 01/88). 2. MTIMATEI)QUANITT'Y of ITA%a1RDOUS SUIKSI'ANC II remaining in the tank (in Gallons), 3. WAS TANK FILLET)WITI1 INERT MA'1:1.iR.IAL? Check 'Yes'or'NO'. APP11C ANI'MUST SIGN AND DA113111E FORM AS IN1)1C:A`M1 D. NSTRUCIION FOR'nTE LOCAL,AGENCH S 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 f'aci'lity number roust 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 all alphabet. If The local agency prefers the State Board to assign the tank number,'please leave it blank. T'1'Ili'11411 R1 ASPONSIMIXI'Y OF IMES'LOCAL AGENCY'IIIAT INSPI:".`S`TII:E3 FACII.TI'Y'I O VERITY 111E ACCURACY 017111E INI1O A`I1ON. '11IE UXW,AGENCY IS RESPONSIBIX,FOR ITIE COMPLYNION OF 11IF 'I 'AL AGENCY USE ONLY'INFORMA=TION IIOX AND FOR FORWARDING ONE FORM "A'AND ASSOC:IA 11°.I) FORM"I.1"(s `1'C)'111I:i WHA&)WING ADDRIsSS. 9WIT 017 CALIFORNIA S1`A'IV WNI ,R R ,YOFTT3.4:;I?S C'ONT'ROL BOARD Clilf", ,, D)VrA 1^ROC'I SSIN6 CEN°IEk PD.IX)X 527 PARAMOUNT,CA IXY