COMPLIANCE INFO_1998-2006 - 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 23266, 25287, and 2-5269 of Chapter 6.7, Division 20, health and Safety Cade 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 EM V- >_ w ALS armor any ether 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 requested information. 4. Use a hard point writing instrument,you ara raking 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location-of the USTT with respect to buildings and landmarks(2711 (a)(8)CCR). . Tank owners must submit documentation showing compliance with state financial respe-� .=Ibility require- ments to the local agency for petroleum RISTs(2711 (a)(1 1),CCR). TOP OF FORM: MARK ONLY ONE ITS 1 Mark an ( )in the bolt next to the item that best describes the reason the form is be;..:, 2. Indicate the DBA or Facility name where the tank is installed. M I. TANK DESCRIPTION - COMPLETE ALL ITEMS ® IF UNKNOWN A SO SPECIF-ill A. Indicate owners tank I ®If there is a tank number that is used by the owner to ides " , (ex. A T7S9). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK FG�;: C. Indicate the year the tarok was installed (ex. 1967). 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 comp r1:,te items B&D. B. Check the appropriate box, C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in ). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service number), if box 1i NOT checked in A. Ill. TANK CONSTRUCTION- MARK ONE ITEM ONLY 1N BOX A, B, C & D 1. Check only one item. in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2.. If OTHER,print in the space provided. Ill. PIPING INFORMATION 1. Circle"A"if above ground circle"U"if underground, and circle both if applicable: . If UNKNOWN circles or if OTHER, print in`space provided. . Indicate the LEAK DETECTION system(s)used to comply with the monitoring r quirdinent for the piping. V. TANK LEAK DETECTION t. Indicate the LEAK DETECTION system(s)used to comply withtfie monitoring requirements for the tank. VL INFORMATION Oil TANK PERMANENTLY CLOSE IN PLACE 1. ESTIMATED DATE LAST USED ONTHNEAR(January, 196I3 or Ol/S3) 2. ESTIMATED QUANTITY of HAZARDOUS SIJ STANCE-remiaining in the tank(in Gallons), . WAS TANK FILLS®WITH INERT MATERIAL? Check"Yews or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS IND[- CATO (see section 2711 (a)(13) CCR _ INSTRUCTION FOR THE LOCAL AGENCIES . .. 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 Mate Board(916)227-43Q3. The facility number must be the same as shown in forma IgA". The tank num r-: ay be assigned by the local agency,however,this number must be numerical and cannot contain an,alphabet. if the local aenpy prefers the Mate Board to assign the tank number,please leave it blank. IT 1S THE RESPONSIBILITY OF .THF.:LOCAL AGENCY THAT INsPErTS,,TFIF FACILITY TO VERIFY TRF .A Ctf® RACY OF THE INFORMATION, 'TH LOCAL AGENCY IS RESPONSIBLE FOR-THE,COMPION OF THE "LOCAL AGENCY USE ONLY" INFORMATION SOX. THE LOCA€. AGENCY SHOULD" RETAIN TGIF ORIGINAL AND YELLOW COPIES. THE PINK C* SHOULD F RETAINED 9Y THE TAN N