COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 252B9 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requestedinfonmodo 4. Use ahard point writing instrument, you are making 3copies. G, Tank owners must submit aplot plan tothe local agency showing the location ofthe USTmwith respect tobuildings and landmarks[2711 (a)(8) CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(11)CCRl TOP OF R]RK4: MARK ONLY ONE ITEM 1. Mark enD{\ inthe box next tothe item that best describes the reason the form inbeing completed. ! 2. Indicate the DBA nrFacility name where the tank isinstalled. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - 8O SPECIFY � A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78S). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C. Indicate the year the tank was installed (ax. 1Q87). D. Indicate the tank capacity ingallons(ax.25.DD0or10.O0Oei .). ||. TANK CONTENTS A. 1. iFMOTOR VEHICLE FUEL, check box 1and complete items B&C. � 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items BQD. B. Check the appropriate b C. Check the type ofMOTOR VEHICLE FUEL(if box 1 |schecked\nA). � D. Print the chemical name ofthe hazardous substance stored inthe tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1 iaNOT checked in/\. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B. C & D 1. Check only one item inTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print inthe space provided. |V. PIPING |NF{JRK4AT|C}N 1. Circle"A" if above ground circle"U" if underground, and circle both if applicable. 2. |fUNKNOWN oinc|e� nrifOTHER, print inspace provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. V|. |NF[)RK3AT|C)N ON TANK PERMANENTLY CLOSED IN PLACE 1. EGT|MATEDDATELASTUSED- MONTHNEAR(January, 18B8orOi/88) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining inthe tank(in Gcd|ons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yeo"or^No". TANK OWNER ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AG INDI- CATED (see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state undergroundaUoua tank identification number is composed of the two digit county numberthe 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)227-4303. 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGEN(�Y IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE P|NKCoSHOULO BE RETAINED BYTHE TAN NER. � _ ��