COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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x INSTRUCTIONS FCR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23;Division 3,Chapter 16, California Code of Regulations and sections 25236,25257,and 25289 of Chapter 6.7, Division 23, Health and Safety Code require tank owners to apply far an I IST'operating perrnit. 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. . This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK NDE - GROUNGTANK INSPECTOR. . Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are.making 3 copies. . Tank owners must submit a,plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks(2711 (a)(I )CCR]. 6. Tank owners must submit documentation slowing compliance with state financial resp= .ibi;tY require- ments to the local agency for petroleum USTs(271"f(a)( 1)CCR], TOP OF o MARK ONLY ONE ITE 1. Mark ari( ') in the box next to the item that best describes the reason the form is 2. indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTIONCOMPLETE ALL ITEMS IF UNKNOWN e SO SPECIF-;" A. Indicate owners tank 1 b If there is a tank number that is used by the owner to ide:.. . . , sex. 70789). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK FG), C. Indicate the year the tank was installed(ex. 1987). C. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). If. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL,chock box 1 and complete items- O. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A d complete items B&D. B. 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 tank and the C.A.S. . (Chemical Abstract Service number), if box lis NOT checked in A. Ill. TANKCONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, B, C 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION; . PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION 1. Circle"A`e if above ground circle"U"if underground,and circle both if applicable. 2. If UNKNOWN circle;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 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 4 y .1.- ESTIMATED ATE LAST USE -MONTHNEAR(January, 1985 or U1;188) . ESTIMATE® UANTI of HAZARDOUS SUBSTANCE r rnaining in the tank(in Gallons), 3. WAS TANK FILLED WITH INET MATERIAL? Check"Yes°or"No'. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM ASINDI- CATED I-CATER [see section 2711 (a)(13)CCRJ INSTRUCTION FORT E -LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction n€tmber,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(91 6)227-430& The facility number dust be the same as shown in form°'A". The tank numbet--rnay be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. if the Iod I Agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL A ENCY"THAT° INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION, THE LOCAL AGENCY;IS RESPONSIBLE FOR THE COMPLETION OF THE 'LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCYSHOUL AIN THE ORIGINAL AND w .YELLOW COPIES. THE PINK C# SHOULD EE RETAINED BY THE TAN. NER.