|
Ank
<br /> INSTRUCTIONS IONS FOR COMPAW FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 22, Division S.Chapter 10, California Code of Regulations anddo 25256, 25287,and 25259
<br /> of Chapter 6.7,Division 20, Health and Safety Code require teak owners to apply for ars LIST operating p rrrrit..
<br /> 1 One FORM "B"shall be completed for each teak for all NEW PERMITS, PERMIT CHANG ES,-REMOV-
<br /> ALS and/or any other TANK INFORMATION 1 GE.
<br /> 2, This fora should be completed by either theEl MIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> 3 pleas �g a, rC uested4
<br /> ������� ����<z��
<br /> Use hard I..€ k,.1 tr itin,,T .6,. rima_ t,, 3'� "a, ks ig 3 cooies,
<br /> S, Tank owners: 'a .,,,A',j is %L a, piot clan to the local agency showing the location of the USTs with respect
<br /> to buildings,and ian nn-,til{r 1271 l )(8)CCR]]
<br /> 0. Teak dwnersmust submit documentation showing compliance with state financial responsibility r puira-
<br /> ment to the[cost agency for petroleum USTa[2711 (a)(1 1)CCR].
<br /> TOP OF FORM; MARK a _ Y ,,:NE" r EM
<br /> 1, lark ars (X) V ITh bo r*xt m the iter; that best describes the reason the fora is being completed,
<br /> 2, Indicate the DBA *,e Facility name where the tank is irsst w=ade
<br /> I, TANK DESCRIPTION - tOOMPLET r.i..l,. ITEMS It. UNKNOWN - SO SPECIFY
<br /> A„ indicate o'vv ons tank lD 9, ,,. rY.`.><;, .1„ "to Ger that is used by the owner to identify the tank ,
<br /> B, In ccat$ thecMMe of the ce-,,=pany'':"'.a na,,n,,,Ja Usecs t1he sank, ex,ACME TANK MFG"
<br /> e _ 7) _.
<br /> a �
<br /> 1..,•, Indicate L'S�., pt.,,C3.� �..,.,» >.e,K.,.'t�. ..'ate., installed ({.<.« i:.".�="64 f'd,
<br /> Indicate the tank capacity in gallons(ex,24,000 or 10,000 etc.).
<br /> IL TANK CONTENTS
<br /> A. 1, IF MOT t„,R V a l E FUEL, ao 1.,,r:box € aind complete items B&C,
<br /> 2, if not MOT' R Y 2ilC£,.E F r<aEL,, c g:,k rh a a pproprlate box in section A and complete Items B&D,
<br /> S, Checkthe appropriaie cox.
<br /> C. Check thNa y a c..Ht CL , . £ ,,'L eif box s is checked in A).
<br /> D, Print the chwrrni,ai narnej�., ,fr.l r„„. ...;.��..,w substance p=ered In the tank:and the r.,',.A, , '. (Chemical
<br /> Abstract Service nu nth er), it, Asx s isk,103Tchecked in A,
<br /> ill. TANK t SRU IO - MARK ONE
<br /> iTEIINAII TONIA,¢'r'' IN SOX A, S,
<br /> 1, Check only one itsm,.rs E OF S'Y`S .M,,TANK MATERIAL, INTERIOR LINING nd CORROSION
<br /> PROTECTION,
<br /> 2, If OTHER, print m the space per:. E de41.
<br /> llv, PIPING INFORMATION
<br /> 1. Circle ' if above g,r)j red circle"Uif rrr de gr ur ,and circle both,if applicable.`
<br /> 2, If UNKNOWN r irc ,",,r,t O ,ITER, print pace,provided,
<br /> 3, Indicate the L 11 D l.r.E,( ,s.,_._ ys..g.rri(s) ,us w t)comply with the monitoring requirement for the piping.
<br /> V, TANK LEAK
<br /> 1. Indicate the t,E1”@K DETECT S, �,m N yaterrr(r.)used to comply with the monitoring requirements for the tank,
<br /> V1, INFORMATION ON T,ANK PERMANEENTILNIf- 'C"LOSED IN PLACE
<br /> 1 e ESTIMATED DATE LAST i IS r,, ..MONTttr�gEAR (January, 1088 r 01/88)
<br /> 2, $BSTI TE QUANTITY
<br /> I of HA��r�tle0faet.S SUBSO"A remaining
<br /> e i ri in the tank(Ire Gallons),
<br /> ns),
<br /> 3.3. TE `TAS N FILLED D�t I §chi,«R? iVIA"$„o- $fi"5' Check
<br /> L? "Yes"or
<br /> "No,"
<br /> T.ANK OWNER OR AUTHO`'=f`ZE EPRESE `ATWE MUST' SIGN AND DATE THE FORM AS INDI-
<br /> CATED
<br /> N I-
<br /> CAT D [see section 2711 (a)( ) CRj
<br /> INSTPUCTION FOR THE w„teiC:"L AG!.NCII~w;aa
<br /> e'i T- undergroundt�l:. storac identificatir ,number is ?xpos r ofdigit county my nu ser,the three digit
<br /> jurisdiction number,the six digit milit nur,al,.er and the six digit tank number. The county and jurisdiction numbers erre
<br /> predetern,nined and can be obtalned by calling It-he State Board(91 S)2,27-4301 The facility number must be the same as
<br /> hown in form "A” The tank number may be assigned by the local agency,however,this number mast be numerical l sd
<br /> cannot cos°r, i rr alphabet, If the,,,, hl .g ,�a td, ra.aState Sir rd tri assign the tank number,r,pl Ileave it blank.
<br /> k.
<br /> IT I THE RESPONSIMUTY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACYOF THE INFORMATION. "t 1•?S_ LOCAL AL ���:. ,CY IS RESPONSIBLE FOIA THE COMPLETION: O THE
<br /> "LOCAL AGENCY USE ..3NLY�' ehr rpt"Mr T.ONBOX, 'nHE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PI.N.HK COPY SHOULD BE R Tll,,t,. 3 BY THE TANK UVVNEl .
<br />
|