COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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INSIRUMONS FOR COMPLETING FORM "B" GENERAL INS-MUMOW, - 1. One FORM "II" shall be completed for each tank for all NEW PERMITS, FFWAH'CHANGHS, RIMO'VAI-S and/or any other TANK INIT)RMAHON CIIANGR 2. This form should be completed by either the PERMIT APP11CAN'll'or the LOCAL AGENCY UNDERGROUND TANK INSPEC`MR- 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. OF FORM: `MARK ONLY'ONE IrlIM 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 i V:, L TANK DESCRTI-IIQN - COMPLE-113 ALL TIVMS - IF UNKNOWN - SO STFXNIY 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. ACW." TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons .(ex. 25,00ti or 10,00;(3 etc,), H. TANK CONFFNTS A. 1. If MOTOR VEHICLE FUEL, check box I 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 CA.S.#. (Chemical Abstract Servi�c number), if box 1 is NOT checked in A. TIL TANK COWIRUC71ON - MARK ONE rIE ONLY IN -BOX A, B, C & D L Check only one item in 'IYPE OF SYSTl-,M, TANK MATERIAL, INTERIOR LINING and CORROSION PROT13MON. 2. If OTHER, print in the space provided. IV. PIPING INFORMN17ON 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. It UNKNOWN, circle; or if OTHER, print in space provided. 3. Indicate the LEAK IA�I-FE-.CIION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DHI1N711ON L Indicate the LEAK. DF:..TECrION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANEIVMY CIX)SED IN PLACE 1. E."MMATED DATE LAST' USER - MON-11'1AYFAR (January, 1988 or 01/88). 2. ESTINNINFED QUAMITY of IIA7ARI)OUSUBS-IANCErema"ning in the tank (in Gallons). 3. WAS TANK.-FlI.J.1,I) WITH INERT MATERIAL? Check 'Yes' or 'NO'. AppucANr mun SIGN AND DAW ITIE FORM AS MICNIED. MrRUMON FOR -171E 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. ri, Is THE RESPONSIBI111Y OFMIE LOCAL AGENCY 11INT'INST1.7ci5111E FAC IIJrY 110 VERIFY 11113 ACCURACY OF ME INFORMMION. 11111, "Al.. AGENCY IS IWSPONSIBLE FOR 1111.11 COMPLEHON OF'IIIE 'LOCAL AGENCY USE ONLY* INFORMA711ON BOX AND MR FORWARDING ONE FORM "A! AND ASSOCIATED FORM 'fr(s) TO`nIE FOLLOWING ADDRE&S. SPATE OF CALIFORNIA SrATF WA`rFR RESOURCILS BOARD C/o &WF -E -PS. DATA PROCHSSING cwnm P.O. BOX 527 PARAMOUNT, (A z 0 0.,