COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS: 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any„ other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the I.,OC'AL AGENCY UNDERGROUND TANK INSPEiCrOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARS ONLY ONE rMW 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 Facility name where the tank is installed. I. TANK DF. SC"RIMON - C OMPLE17E All. rIFAS - 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. 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.). 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 & 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 CA.S* (Chemical Abstract Service number), if box 1 is NOT checked in A. M. TANK CONSTRUCTION - MARK ONE I113M ONLY IN BOX A, B, C & D I. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR 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. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DLTIFJCITON 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST' USED - MONTII/YEAR (January, 1988 or 01/88). 2. ESTIMATED QUANTI'T'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITII INERT MATERIAL? Check 'Yee or'NO'. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. 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 inform "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 RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS "THE FACILITY TO VERIFY TIER ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS, STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O &W.E.E.P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 1* 0