COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLENG I 'B" GENERAL IN.SIRUCIIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, ,REMOVAIS and/or any other TANK INFORMA11ON CHANGE, 2. This form should be completed by either the PERMrI APPLICANT 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 1copies. 1nP OF FORM:'MARK ONLY ONE CIEM" L 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:RIVI ION-C OMPI.1.:'v AL1.rI13MS-IIx 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 TAiNK 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.). H. TANK CONT ?NI'S 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 C.A.S.#. (Chemical Abstract Service number),if box 1 is NOT checked in A. III. TANK CONSE'RUCTiON-MARK ONE rl."LM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,'TANK MATERI.AI.., INTERIOR LINING and CORROSION PROTECIION 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 DETE,CI'ION 1. Indicate the I.,HAK DEI'ECI7ON system(s) used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY C1OSI?D IN PLACE? 1. ESTIMATED DATE LAST USED-MONI'It/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTPI:Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WI'I'll INERT"MATERIAL?Check'Yes'or'NO'. APP1.IC.ANT MUST'SIGN AND DA11?'RIE,FORM AS INDICK1131). IN.SIRUC110N POR'111I:LOCM.:AGENC IF-S 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 (91.6)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. Tl'IS 11IE?RFSPONSIBHXI'Y OF TUE LORAL AGENCY THAI'INSPECIS'I71I?FACILFI'Y TO VERIFY TILE ACCURACY OF TIH!INFORMATION. 'I7IE?LOCAL AGENCY IS RESPONSIBLE FOR'1711E COMPIHTION OF T1II3 'LOCM,AGENCY USE ONLY'INFORMA'110N BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED FORM'B"(s)1'O 111E FOLLOWING ADDRESS. STA I E OF CALIFORNIA STATE WNIMR RESOURCIS CONI1tOL BOARD C/O S.W:E.E.P.S. DATA PROCESSING CEIVIMR P.O.BOX 527 P MOUNI',CA 90723