COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMONG FORM "B," GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code ofRegulations and sections 25286, 25257, and 25259 of Chapter 5.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit, 1= One FORM ",B"shad be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/oar any other TANK INFORMATION ATION C:I i At GE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND UND TANK INSPECTOR. 3. Tease type or print clearly all requested information. . Use a hard point writing instrument, you are making 3 codes, 5. Tank owners must submit a plot plan to the local agency showing the locatioan of the USTs with respect to buildings and landmarks[2711 (a)(B) CCR]. . Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs(2711 (a)(11) CCR]. TOP OF FORM: MARK ONLY ONE IT EM 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the CUBA or Facility risme where the tank is installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS A IF UNKNOWN - SCS SPECIFY A. Indicate owners tank IB##- If there Is a tank number that is used by the owner to identify the tank(ex. AB7g73S). B. Indicate the name of the company that manufactured the tank(ex. ACME E TANK MFG), G. Indicate the year the tank was installed (ex. 1837), , Indicate the tank capacity in gallons (ex.25,000 or 13,00etc,). IL TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&G. 2_ If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&B: B. Check the appropriate box, C. Check the type of MOTOR H VEHICLE FUEL(if boy 1 is checked In A). B. Print the chemical name of the ha ardor s substance stored in the tank and the C.A.S. . (Chemical Abstract Service number),if box 1 is NOT checked in A. III. TANK CONSTRUCTION - MARK CANE ITEM ONLY IN BOX A, B, Cf 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" 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. TAMC LEAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the r onitoring requirements for the tank, L INFORMATION TANK PERMANENTLY CLOSED IN PLACE 1: ESTIMATED BATE LAST USED- MONTH/YEAR (January, 1535 or 01158) 2, ESTIMATEDQUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). S. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No", TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- TE [see section 2711 (a)(1 ) CC INSTRUCTION FOR THE LOCAL AGENCIES The state ndercaround storage tank identification number is composed of the we 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(315)227-4333. The facility number roust be the same as shown in form „Ate. 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. TIME 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 COPY SHOULD BE RETAINED BY T"I"LE TANK OWNER. 0