COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM n,B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16,California Code oaf g lations and sections 25236,25237,and 25289 of Chapter 6.7, Division 20, Health and Safety Cuda require,tank owners to apply for an UST operating permit,, f One FOR "B"shall be completed for each tank for all NEW PERMITS, I E 'MIT CI MG,tS, REMOV- L and/or any other TANK INl`C W011ATIC` N CHANGE, 2 l.is 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 paint writing instrument, you are making 3 copies, 5. Tank owners must submit a plot pian to the local agency showing the location of the USTs with respect to buildings and landmark [2711 (a)(8)CCR], 6, "Tank owners must submit documentation showing compliance With atat 'financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(t 1)CCR], TOP OF FORM: MARK ONLY ONE ITE 1. Mark an(X) in the box next to the item that bast do scribes the reason the form is being completed.r 2. Indicate the DBA or Facility name where the tank i 'installed. Ia TANK DESCRIPTION - COMPLETE ALL ITE - I `UNKNOWN - SO SPECIFY A. Indicate owners tank ID#a if there is a tank number that is used by the owner to identify the tank(ex. z¢ AB70739). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C. Indicate the year the tank was installed(ex. 1937). . 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 item 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D 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 stared in the tank and the C.A.S. , (Chemical Abstract Service number), if box lis NOT checked in A. Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOXA,_1 , C & C 1.. _ Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION, _ If OTHER,print in the space provided. lV. PIPING INFORMATION 1. Circle"A"if above ground circle"U"if underground,and circle.-both if applicable. . If UNKNO N.circleg 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. Indicate the LEAK DETECTION s stems)used to comply with the monitoring requirements ents for the tank. VIa INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED MONTHNEAR(January, 1968 or 01/33) 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). . WAS TANK FILLED WITH INERTMATERIAL? Check"Yes"or"No", TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED N I-CATED [see section 271 (a)(1 3) 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 State Board(916)227-430& The facility number must be the same a shown i "A". The to num er:may be assigned by the local agency,however,this number must be numerical and cannot cont in in 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 ACLU- t. RA F 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 PINK C Y SHOULD BE RETAINED? BY THE TANK NER.