COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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m INSTRUCTIONS iS FOR COMPLETING FORE SER , GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulationsand sections 25256, 25267, and 25269 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 PERMIT'S, 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 requested information. 4. Use a hard point writing instrument,you are making 3 copies, 5. Tarek owners must submit a plot plan to the local agency showing the location of the LISTS with respect to buildings and landmarks[2711 (a)(3)CCR], 6. Tank owners must submit documentation shoeing compliance with state financial respf�, require- ments to the local agency for petroleum€lSTs[2711 (a)(11)CCR). TOR 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 b .T ; 2. Indicate the DBA or Facility name where the tank,lvinstalled. 1. TANK ESQ 1RT1 m COMPLETE ALL- ITEMS,® `IF UNKNOWN m ; O RECIF`° A. Indicate owners tank I ®If there i a tank number that is used by the owner to ides-",i (ex. A 76739). E, Indicate the name of the company that manufactured the tank(ex.ACME TANK FG), C. Indicate the year the tank was installed(ex. 1957). O. 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 iters C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items R&C. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked 14_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 11s NOT checked in A. 111. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A,,. , C' 1. _ Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING ar�d CORROSION PROTECTION, If OTHER, print in the apace provided. IV. PIPING,INFORMATION 1. Circle;"A"If above ground circle"U"if undergrounds and circle both if applicable: . If UNKNOWN circles or if OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1 o Indicate the'LEAK DETECTION system(s)used to comply With the monitoring requirements for the tank. I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED R_ ONTHNEA (January, 1935 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), . WAS TAMC FILLED WITH INERT MATERIAL? Check"Yes"or"No" TANK NER OR AUTHORIZE® REPRESENTATIVE UST SIGN AND DATE T � O a 4 1 ATEO [see section;2711 (a)(13) CCR] a3 INSTRUCTION O THE LOCAL AGENCIES The state underground storage tank identification number is composed of the twQ digit county number,the three digit` jurisdiction number,the six digit facility number'a nd`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 forma"A". The tank number may be assigned by the local agency,'however,this number mist be numerical and cannot cont iman 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 AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL. AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD <RETAIN THE ORIGINAL AND YELLOW COPIES. THE RINK C* SHOULD BE RETAINED BY THE TANK OWNER.