|
711-17FTIRW
<br /> iNSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTROZrJONS T k"_
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25286,25287,and 25289
<br /> of Chapter 6.7,Division 20,Health anis Safety Code' erre tank airk for an UST operating_ permit.
<br /> �.a „ P 9 p
<br /> -.
<br /> 4 ,1 ne F . "B"shallbe completed for,$a��t���l�z tankfaF t hAITS, PERMIT CHANGES, REMQV,,�.,
<br /> LS a ' arty other TANK INFORMTfON CHANGE:,
<br /> 2t ,x ;is ' ould be completed by either the PERS IT,�PPP�„ICAW or the LOCAL AGENCY..UNDEA _
<br /> G
<br /> l D TANK INSPECTOR.
<br /> - ,-
<br /> � . a
<br /> I:!lease type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> A -5. a-. Tank owners must submit a plot plan to the,local-agency showingth0ocation of the USTs with` pe
<br /> to buildings and landmarks(2711 (a){8)CCR],
<br /> _. 6. Tank owners must submit documentation showing compliance with sta*-financial respn sibilityxequite-
<br /> ments to the focal agency for petroleum USTs 2711 (a)(1 1CCR
<br /> -TQF, pF FORM; MARK ONLY ONE ITEM ._... w .. ..._�_-,. .
<br /> 1. ;.Mark an(X) in the box next-toVwitemlhat best describes the ",. >�form is be:r. to .
<br /> e 2. Indicate the DBA or FaclWname where the tank is installed.
<br /> I. TANK DESCRIPTION- COMPLETE ALL ITEMS - IF UNKNOWN Std SPECIFY
<br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to tderis°t
<br /> AB70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG).
<br /> C. Indicate the year tYte tank was installed(ex, 1987), f
<br /> D. Indicate the tank rapacity in gallons(ex.25,000 or 10,000 etc.)..
<br /> Ii. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete mems'B&C.
<br /> 4 not:MQTOR VEHICLE FUEL,check the appropriate box in section.A and complete items 8&D.
<br /> B. Chegk,# ropriate box:
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked'
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical
<br /> Abstract Service number),if box 1.is NOT checked in A.
<br /> lll. TANK CONSTRUCTION - MARK ONE ITEM ONLY fi+ `WX- A, 1% �Y &' D
<br /> :check only one item in_TYPE OF SYSTEM,TANK ,11�ti E§ ►OR LINING arid CORROSION
<br /> PROTECTION.
<br /> -_ - Z if OTHER, print In the space provided,
<br /> W. ,. .-.PIPING INFORMATION �;::: .►
<br /> . ,Circle"A" if aboveground circle"U"if-underground,and circle both if applicable.; t
<br /> 2. If UNKNOWN circle;or if OTHER,print in space provided. r'
<br /> 3. Indicate lfte LEAK DETECTION system(s)used to comply with,t monitoring requirement for the ping.
<br /> ,TANK LEAK DETECTION
<br /> 1. indicate the LEAK DETECTION system(s)used to comply with the motoring requirements for the t�k
<br /> Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE,--
<br /> 1. ESTIMATED-J?ATE LAST USED-MONTH/YEAR(January, 1988'6r,01/88)
<br /> . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in GWIonsy.`
<br /> �_. '3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No*.
<br /> $ T�►T�IK
<br /> OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANE SATE THE FG3RM AS INDI.-.
<br /> CATED,jsee section 2711 (a)(13) CCRj
<br /> INS�i'Rll 'I'tON FOR THE LOCAL AGENCIES-
<br /> The
<br /> GENCIES The state underground storage tank identification number is composed of the two digit county number,the three f36glt
<br /> jurisdiction-number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are
<br /> .";redetermined and can be obtained by calling the State'Board(916)227-4303. The facility'number must-be the nrie at,
<br /> own in form"A". The tank number may be assigned by the local agency,however,this number must be numerical and
<br /> } cannot cont41nlan alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> IT` IS'-THE RESPONSIBILITY OF THE-LOCAL AGENCY-THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> KAL AGENCY USE ONLY° INFORMATION BOAC.JHE I,�?CAL AGENCY SHOULD RETAIN THE ORIGINAL ANQ ,.
<br /> LOW, COPIES. THE PINK.: SHCX[1I, S BE I ETAINEDYi3Y THE TANK WNER: "
<br /> . .
<br /> sA&
<br />
|