COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM „R" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Cade of Regulations and sectiones 25236"25287, and 25269 of Chapter 6.7. Division 20, Health th and Safety Cade require tank owners to apply for an UST operating permit. 1. One F, ,"R"e shall be completed fdrea8h tank frac all NEW PERMITS, PERMIT CHAT GES, R MOV- ALS a dtor any other TANK INFORMATION CHANGE, 2. This form should be completed by either the PERMITAPPLI.CANT or the LOCAL AGENCY UNDER- 'GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. US 5. Tank owners must submit a plot plant to the local-agency showing the location of the LdSTs with respect to buildings and landmarks(2711 (a)(S)CCR]. . Tank owners must submit documentation shoring compliance with state,financial resp=-, ., i,i#y require- ments to the local agency for petroleum USTs(2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITE 1. Mark an(X) in the box next to the item that best describes the reason the form is bei- 2. e 2. Indicate the DBA or Facility name where the tank is installed. . TANK DESCRIPTION - COMPLETE ALL ITEMS a IF UNKNOWN SPECIFY' A. Indicate owners tank I®#® If there is a tank number that is used by the owner to nder;. r (ex. AB707 9). Indicate the name of the company that manufactured the tank(e .ACME TANK MFG. x. C. Indicate the year the tank was installed (ex. 1967). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.), ®° II. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items B&C. 2. If not MOTOR VEHICLE FUEL,chock the appropriate box in section A and com lele,items E&D. E. 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 fink and the C.A.S,#. (Chemical Abstract Service number), if box 1 .is NOT checked in A. Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX At. B, C 1, _..,_Check only one item in TYPE OF SYSTEM,TALK MATERIAL,,INTERIOR LINING an,rJ CORROSION `RROTECTIO . 2. If OTHER, print in the space provided, IV. FIRING INFORMATION a m® 1 Circle"A"if above ground circle"Ll"if underground,and circle both if applicable, 2. If UNKNOWN circle-, or if OTHER, print in space provided. 3. Indicate the LEAD DETECTION system(s)used to comply with the monitoring requiretnent for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAD DETECTION system(s)used to comply vvith the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED®ATE LAST USED ONTHNEAR(January, 1958 or 01/36) 2. ESTIMATED-QUANTITY of HAZARDOUS SU STANCE remaining in the tank(in Gallons), . WAS TALK FILLED WITH INERTMATERIAL? Check"Yes"or"No". TANK OWER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see sections 2711 (a)(13) CCR INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the.twpcligit cdunty,rau€ri er,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)227-4303. The facility number must be the same as shorn in form."A°". The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain-an alphabet._ f 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 A C€!- RACY OF T i INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY'USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD,RETRAIN THE ORIGINAL AND YELLOW COPIES. TIDE PINK C* SHOULD BE RETAINED BY THE TANK6WNER.