COMPLIANCE INFO_1998 REMOVAL AND INSTALL

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INSTRUCTIONSFOR C MPLE'rI G FORM."B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division ision 3, Chapter 16, California Code of Regulations and sections 26286, 25237, and 25289 of Chapter 6.7,DWsion 20, Health and Safety Code require tank owners to apply for an LAST operating permit. 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS E OV- ALS and/or any other TANK INFORMATION CHANGE. 2, €his form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK IN 'OR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies, 5. Tank own-emogslsubmit a plot plan to the local agency showing the lbcati fth&U Ts with respect to buii Ings and landmarks(2711 (a)(6)CCR]. 6. Tank-e, ers ust submit documentation showing co6olihbole with,Mate financial responsibility require- - ments e wire- ments to-the,local agency for petroleum LISTs(2711 (a)(11) C R]. TOES OF FORM: MARK ONLY ONE ITEM 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. 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank IB#-If there is a tank number that is used by the owner to identify the tank(ex. AB70739), B. Indicate the name of the company that manufacture the tank(ex.ACME TANK MF )-;- C. Indicate the year the tank was installed(ex. 1967). D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). If. TANK CONTENTS 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). C3. Fridit e'chemical name of the hazardous substance stored in the tank and the C.A.B. . (Chemical Abstract Service number), if box 1 is NOT checked in A. Ili. TANK CONSTRUCTION =MARK ONE ITEM ONLY IN BOX A, B, C & IB Check only one item in TYPE OF SYSTEM,TANKMATERIAL, INTERIOR LINING and CORROSION PROTECTION. _.. .. _.. , If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A"if above ground circle "L)" if underground, and circle'both if applicable. 2. If UNKNOW circler or if OTHER, print in space provided. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 9 1. Indicate the LEAS- ETECTION system(s)used to comply with the m nitoring requiremeAs for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1= ESTIMATED BATE LAST USED-MONTHNEAR (January, 1936 or 01183) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). . WAS TANK FILLED WITH INERTMATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED (see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state undergroundstorage t nk identifi I cation number s..c6m osed of the two digit county number,tba three,oliot jurisdiction number,this six digit facility number and the six digit tank number. Thbbgunty and jurisdiction nu-tuber are redetermined and can be obtained by calling the Mate 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 1 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 RESPONBIBILITY'OF THE LOCAL AGENCY THAT INSP'ECT'S THE FACILITY TO VERIFY THE ACCU- RACY, OF TIME INFORMATION. THE LOCAL AGENCY 13 RESPONSIBLE FOR THE COMPLETION OF THE ®"LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN H ORIGINAL Al l YELLOW COPIES: THE PINK Co SHOULD BE RETAINED BY THE TAIL NER,