COMPLIANCE INFO_2001-2003 - Laserfiche WebLink

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4 INS71'RUC717IONS MR COMP111170 FORM'B* GENERAL INS!RUC;IIONS- 1. One FOR.M "B"shall be completed for each tank for all NEW PrRmn-Is,PE.RMJ`I'0IANGRS, RFN4OVAI,,S and/or 7v other TANK INIX)RMNI'lON CIIANGE- 2. This form should be completed by either the PERMIT APPLICANTor the 1f)(:AL AGENCY UNDEIRGROUNT)TANK INSPEM'OR. 3. Please type or print clearly all requested information. 4Use a hard point writing instrument,you are making 3 copies, ry '17OP OF FORNt-*MARK ONLY ONE 117113W 1. Mark an (X) in the box next to the item that best describes the icason the form is being Completed. 2. Indicate the D13A or.Facility name where the tank is installed. 1. TANK DESCRIVITON-COMP1,13TE ALI.rMqAS-IF UNKNOWN-So SPI 11'Y A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank (c>: B. Indicate the name of the company that manufactured the tank(ex. ACMIF"TANK 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.). 11. TANK CONIIWI*S A. 1. If MOTOR VEIIICLF FUEL,check box .l. 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 Mum 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 Servide: number),if box 1 is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE TrtW ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYS'IT-,'M,TANK MA'ITRIAL, IN'TTRIOR LINING and CORROSION PROTEC110'N. 2. if arnER,print in the space provided. TV. PIPING INFORMN17ON 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if 0111ER,print in space provided. 3. Indicate the LEAK Dri-ECTIONsystem(s)used to comply with the monitoring requirement for the piping. V. TANK LJ!AK DITURC717TON 1. Indicate the LEAK Dri'ECTION systcm(s) used to comply with the monitoring requirements for the tank, VI. INFORMATION ONTANK PERMANEM1,Y(U)SW)IN PIA0! 1. ES'J`tMATFD DAIM I.AST USED -MON'nI/YF.AR (January, 1988 or 01/88). 2. PSHMATED QUAN`ITIY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK TILLED wim INERT MA'T'ERIAL?Check 'Yes'or'NO'. APPIICAW MUST SIGN AND DATE 111111 FORM AS INDICA110. IN,VRIJ(-'nO.N FOR,nwI.O(:AL AGINCIF-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 number,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"1'1113 RESPONSIBRXIT OF THE I.O(7d.AGENCY IIIAT INSPIXTS 11IF FAC IIXIN VERIFY1111i ACCTJRACY OF 71111113 INFORMAITON. 11111 LOCAL AGENCY IS RFSPONSIBLIi FOR'nwCOMPLIq1ON OF 71IF *I,OCAI.AGI94C`Y USE ONI.Y*INFORMA11ON BOX AND FOR FORWARDING ONE FORM'A7 AND ASSOCIAITO FORM-13'(s)TO 11113 FOLLOWING ADDRESS. STA1E OF CALIFORNIA 9r)V1E WR'I'ER RHSOURCES CONTROL BOARD C/o Smsm-P.S. DA'T'A PRO(TLSSING CF1VI`E-R P.O—BOX 527 PARAMOUNI-,CA 90723