COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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IN9I.'RUC!1'IONS 17OR CC? P _,LING FORM "B" GENERAL IN U C) 1. One FU "E3" shall be completed for each tank for all NEW P M, PERMrr CHANGES, RFMOVALS and/or any other TANK INPORMAIION C'IIANGF. 2. This form should be completed by either the PERMff APPUC/Mror the LOCAL AGENCY UNDERGROUND TANK 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. '17OP OF FORM. ONLY ONE 1. Mark an, "(JC) 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. TANK DF-S . 11ON = ' PI..1 IL? All, rt..: - IF UNKNOWN -, SpM, IrSP 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 FG.). C. Indicate the year the tank was installed ; (ex. 19137). D. Indicate the tank capacity in gallons (ex 25, or 10,000 ctc.). II. TANK CONTENIN A. 1. If MOTOR VI1HICLF; FUEL, check box 1 and complete items Ei & C. 2. If not MOTOR VEHICLE FUI:sL, 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 I is checked in A). I). 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. III. TANK CCANSTR JC'ITON - MARK CA i nim . C)NLy iN PA)XA, 11, C & D 1. Check only one item in TYPE O SYSTEM, TANK MATERIAL, INTI RJOR LINING and CORROSION PRC)TE?.0 10N. 2. If OTHER, print in the space provided. . PIPING INFORMATION L Circle A if above ground; circle is if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if C)TELE P, print in space provided. 3. Indicate the LEAK DI IT;C`I1ON system(s) used to comply with the monitoring requirement for the piping. V. TANK I IrAK T.1371I C."I'ION 1. Indicate the LEAK DISI EC"TION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON "r PER ANFg 11,Y CIA)SED P . C°I? L 1 911MATED DATE LAST USED - MC:) I/YEAR (.January, 1.988 or 01/88). 2. ES'TIMA'TED QUANFITY of HAZARDOUS ,SUBS"TANC.E remaining in the tank (in Gallons). 3. WAS TANK MLLE;D WrI'I-I INERT MATERIAI ? Check 'Yes' or 'NC)'. APPI1CANr MUSr SIGN AND DATE1HE FORM AS INDRA110. INSTRU(-nON I IS 111, LOCAL AGFNCITIS 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)739-2427_ 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 T 1 RESPONSIBILITY OF T1113I AL AGFF.NC 'I7-IA'r INSPEttCIN I III:? ICAC IIgiI Y 1t1 i&LI "I1I ACCURACY OF 1I1Ii INFORMATION. 11113 LOCAL L AGEs'NC Y IS ROSPONSIBLE FOR ,nm CCAMPLUITON C)Ip °r[IE "I , AGENCY USS ONLY" INFORMAITON BOX AND MR FORWARDING ONE IK)"A" AND AS,S{)C:IA'I7 D FC)-13-(s)TO F'EIE: FOLLOWING ADDRESS. A"I E OF C.AI,IMRNIA SI`1YI7? WA°I.MR RISOURCES C O 'ROL BOARD C/o .W1. E: P.S. IAXFA PROCESSING C'IF .I` 3R P.O. 527 FARAMOUNI7, CA WM