COMPLIANCE INFO_1992-2002 - Laserfiche WebLink

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or lNS`IR1JC'I1ONS FOR COMPLE17ING FORM'13- GFwRAi.imsmucnow L One FORM "B"shall be completed for each tank.for all NUW PFRMTIN, PERMI'I'CHANGE.S, REOVAUS and/or any other TANK INFORMA'ITON CHANGF- 2. 'I'his form should be completed by either the PERMIT'APPI1CAN1.'car the LOCAL AGENCY UNDERGROUND I*ANK INSPI."..OR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies, 'rOP OF FORW"MARK ONLY ONE rl'l:'M* 1. Mirk 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. 1. 'PANIC DESCRIP`11ON-(,'OMPT.11'13 ALI.171'EMS-117 UNKNOWN-So SPEC317Y A. Indicate owners tank 117 # -If there is a tank number that is used by the owner to identify the tank(ex.A1370789). 13. Indicate the name of the company that manufactured the tank(ex,ACME TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). 17, Indicate the tank capacity in gallons(ex. 25,00 or 10.000 etc.).' 11. 'TANK WNHWIN A. 1. If MO'I'OR VEHICLE FUEL,check box I and complete items B &- C. 2.If not M(yI'OR VEIIICLEi 17U13L,check the appropriate box in section A and complete items B D. B. Check the appropriate box. J C. Check the tvPC of MO'I'OR VEHICLE FUF1(if box I is checked in A). type D. Print the chemical mune of the hazardous substance stored in the tank and the C,A.S.#. (Chemical Abstract Service number), if box I is Nur checked in A. TIL 'IANK MNSTRUC11ON-MAItK ONE lr17,W ONLY IN B(-.)X A,D,C&D 1. Check only one item in'I'YPE OF SY411,1\4,IANK MA'11.3IRIAL,I.%-M,.RIOR LINING and CORROSION PR(-)'IE(.-rION. 1 If 011JER, print in the space provided. IV. PIPING INFORMA711ON 1. Circle A if above ground; circle U if underground; and circle both if applicable, 2. If UNKNOWN,circle; or if OTTTER,print in space provided. 3. Indicate the LEAK D1.7 I-L(71ON system(s) used to comply with the monitoring requirement for the piping, LEAK DINW-31ON 1. Indicate the LL,-\K DE'ff',C'I'ION system(s) used to com`Ply with the monitoring requirements for the tank. VL INFORMAIION ON TANK.PI RMANIWIIY(HOSED IN PLACE, 1. &STIMA11.11) DA'111 I.A51'USED -NJONIII/YEAR(January, 19,98 orO:I./88). 2. ESI'IMial)QUAP11'11N of HAZATU)OUS SUBS'IANCE remaining in the tank(in Gallons). 3. WAS TANK 1`141Y.I.)WrlIT INERT MATERIAL? C.heck 'Yes'or'NO', APPLICAN17 MUST SIGN AND DIVIM'11111 FORM AS INDI(W17E11 INS-I'RUCIION MR11IF LOCAI,AGENCIT—IS 17he 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. 'I I he county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 'I'lic facility number must be the same as shown in form "A". The tank number may be assigned by the local agenc-r. 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. Tl'IS'111E,RE-SPONSIBI111"Y OF171E LOCAL AGI.NCY111AT INSPIX71N, 111H FACILUT TO VEMIFY1711E ACCURACY OF'1111?,INFOJMNIJON, 'ITIS r.OC AL AGENCY IS RESPONSIBLI.;FOR'171117 COMPLE11ON OF 111I.i. "LOCALAGEWY USE ONLY*INFORMS110N BOX AND 14OR FORWARDING ONE.IDRM*A"AND ASS0Cl/VIE1) FORM W(s)1-0 7111.1 FOI1..OWING ADDRESS. SIWJ'E OF CAI. FORNIA �Z!Wrl W)Yil�R IYV,77� A, -,� P.O1K)X 527 PARAMOUMI',CA%M