COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COM TING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter'10,California Code of Regulations and sections 25280, 25237, and 25289 of Chapter 5.7, Division 20, Health and Safety Code require tare 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 and/or any other TANK INFORMATION CHANGE. 2. This forret should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. R. 3. 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 prat plan to the local agency showing the location of the LISTS with respect to buildings and landmarks[2711 (a)(3) CCR). 0. Tank owners roust submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum U STs[2711 (a)(11) CCR]. TOP OF FORM: MARK K CONLY ONE ITEM 1, dark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the IORA or Facility name where the tank is installed. I, TAT DESCRIPTION - COMPLETE ALL ITEMS ® IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID If there is a tank number that is used by the owner to identify the tank(ex. AP707S9). R. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFT). C. Indicate the year the tank was Installed (ex. 1987), , Indicate the tank capacity in gallons (ex. 25,000 or 10,399 etc,). II. 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 complete items S&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 S.A.S. . (Chemical Abstract Service number), if box 1 is NOT checked in A. CII. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN SOX A, E, C 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LININS and CORROSION PROTECTION, 2. If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A" if above ground circle"U"if underground, and circle both if applicable. 2. If UNKNOWN circle;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 system(s)used to comply with the monitoring requirements for the tank, VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USED -MCONTHIYEAR (January, 1900 or 01133) 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3, WAS TANK FILLEDWITH INERT"MATERIAL? Check"Yes"or"No", TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND TATE THE FORM AS NDI- . SATED [see section 2711 (a)(11 3) CCR) INSTRUCTION FOR THE LOCAL AGENCIES The state undercaround storage tank identification number is composed of the two digit county number, the three digit jurisdiction num er,the six digit facility number and the six digit tare number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (910)227-4303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain an 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 ION OF TIME . "LOCAL AGENCY USE ONLY` INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER, is