COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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INS1pRU(71lONS IX)R COMPLErl'ING FORM 1r GENERAL IMSTRIUCIIONIS- L One FORM "B" shall be completed for each tank for all NEW PERIVIrl'S,PERMIT C1LANGFS, RE MOVAI.-S and/or any other TANK INFO 'PION CHANGE, 2, ':This form should be completed by either the PERMIT APPUCANI'or the LO(:AL AGENCY UNDERGROUND TANK INSPIXFOR- 3. Please type or prim clearly all requested information. 4. Usc a hard rx)iw writing instrument, you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE nVM" 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 DESCRUY17ON-COMPLUIll All,TI`EMS-W UNKNOWN-So SPMUN 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), 1). Indicate the tank capacity in gallons(ex.25,(W or 10,W0 etc.). It. TANK(X)NI171VI5 A. 1. If MOTOR VEHICLE FUFI,,check box 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 I 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. 111. TANK CONSIRU(NION-MARK ONE rI`FM ONLY IN BOX A,B,C&1) L Check only one item in TYPE OFSYSTF.M,'TANK MNI'ERIAL,INTIERIOR LINING and CORROSION PRarr-,criON. 2. If OTHER,print in the space provided. IV. PIPING INIX)RMKIION I. Circle A if above:ground; circle U it underground; and circle both if applicable. 2, If UNKNOWN,circle; or if OTHER,print in space provided, 3. Indicate the LFAK DI171-E('FION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DLrn'.CIION 1. Indicate the LEAK DFTEC17ION system(s) used to comply with the monitoring requirements for the tank. VI. mioitmxnON ON TANK PERMANENII.Y CL DSED IN PLACE 1. ESTIMATED IMATED DATF.LASFUSF�D-MONr1'1i/YEAR(January, 1988 or 01m), 2. ESTIMATID QUANITFY of HAZARDOUS SUBSTANCE remaining in thetank(in Gallons), 3. WAS TANK FIQ-1 -�F )WITH INF XI-MAITRIAL? Check 'Yes'or'NO'. .1 APPIlCANI`MUST SIGN AND DATF17TE FORM AS INDICNIVJ), IN5rRUC'IlON FOR"IIID 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 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 TILE RRSW)NSIBHXrY OF"ITIS LOCAL AGINC-Y III/V.1'INSPE('I'S'll IE FACII.Xry IT)VERIFY 71111? ACCURACY OF THE IM?0RMNI7ON. IIIE LOCAL AGENCY IS RESPONSIBLE FOR IIII?COMP11HION 017,11111 "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR IX)RWARDING ONE FORMA"AND ASSOCINI'ED FORM'B'(s)-1101711?Ik)I-IOWING ADDRESS. IMYVIE 017 CALIFORNIA WA'171,"R RF,`X)U'RCIU9 U)YM,01,10 ART) DA`rA PROC'IiSSING (IWJ`E�R P.O.BOX 527 PARAMOUNI',CA 90'M