|
"J
<br /> INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<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 and Safety Code require tank owners to apply for an LIST operating permit,
<br /> 1 One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE,
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR, ' _
<br /> 1 Please type or print clearly all requested information.
<br /> 4, Use a hard point writing instrument, you are making 3 copies.
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect
<br /> to buildings and land'Marks(2711 (a)(8) CCR].
<br /> 6, Tank ownTs must submit documentation showing corypliance with state financial responsibility require-
<br /> ments to the local agency for petroleum LSTs[2711 (a){11) CCR],
<br /> TOP OF FORM: MARK ONLY ONE ITEM-
<br /> 1. Mark an (X) in the box next to theitem that best describes the reason the form is being completed.
<br /> 2. indicate the DBA or Facility name where the tank is installed.
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A, Indicate owners tank ID If- If there is a tank number that is used by the owner to identify the tank(ex.
<br /> AB70789).
<br /> B. Indicate the name of the company that manufactured the tank (ex,ACME TANK MFG),
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.),
<br /> 11, TANK CONTENTS
<br /> A, 1, IF MOTOR VEHICLE FUEL, check box 1 and complete items 6& C.
<br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D,
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A).
<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 /> Ill, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1, Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2, If OTHER, print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> 1. Circle "A" if above ground circle"U" if underground, and circle'both if applicable.
<br /> 2, If UNKNOWN Girole; or if OTHER, print in space provided.
<br /> 3. Indicate the LEAK DETECTION systern(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> 1, Indicate the LEAK DETECTION system(s)used to compty with the monitoring requirements for the tank.
<br /> V1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LAST USED - MONTHNEAR (January, 1988 or 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes" or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESEN TATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED (see section 2711 (a](13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of thertwo digit county number,the three digit
<br /> jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board (916)227-4303, The facility number must be the same as
<br /> shown in fori-fT,"A". The tank number may be assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an 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 ACLU-
<br /> RACY OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER.
<br />
|