|
INSTRUCTIONS FOR COMPLETING FORM "B`
<br /> GENERAL INSTRUCTIONS
<br /> Section 2 71 1 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 UST 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 ATI ION CHANGE,
<br /> 2, This form should be cornpleted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> 3. 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 landmarks[2711 (a)(8)CCR].
<br /> 6. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs (2711 (a)(11)CCR].
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, Mark an (X) in the box next to the item 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 there is a tank number that is used by the owner to identify the tank(ex.
<br /> A1370789).
<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 /> if. TANK CONTENTS
<br /> A. 1, IF MOTOR VEHICLE FUEL, check box 1 and complete items 8&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 1 is checked in A).
<br /> C. 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 /> 1Circle"A" if above ground circle "U" if underground, and circle both if applicable.
<br /> 2. If UNKNOWN circle; or if OTHER, print in space provided,
<br /> 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> 1 Indicate the LEAKIDETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED- MONTH/YEAR (January, 1988 or 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining'n the tank (in Gallons).
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a)(1 3) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county number,the three digit
<br /> jurisdiction number, the six digit facility number and the six digit tanknumber. 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 form "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 ACCU-
<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 C(f SHOULD BE RETAINED BY THE TANK NER.
<br />
|