COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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-_INSTRUCTIONS FOR FOR COMPLET|NG FORM "B" GENERAL INSTRUCTIONS Section 2711cf Title 2S. Division 3. Chapter 1B. California Code ofRegulations and sections 25288. 2S287. and 2528Q of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. 1One F<]RK8 "B"shall be completed for each tank fo K NEVV PERMITS, PERMIT CHANGES, REMOV- ALS and/or any th TANK INFORMATION CHANGE. 2, This form should becompleted byeitherthe PERKX{TAPPUCANT orthe LOCAL AGENCY UNDER' {)IP[)UNDTANK INSPECTOR. 3, Please type orprint clearly all requested information. 4� Use ahard point writing instrument,you are making 3copies, 5. Tank owners must submit a plot plan tnthe local agency showing the location o/the USTswith respect 1ubuildings and landmarks [2711 (a)(8)CCR]. 8. Tank owners must submit documentation showing compliance with state financial responsibility require- mentsto\he|mca|aDencyforpetoo|eumU8To[2711 (a)(11) CCRl TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA orFacility name where the tank ioinstalled. |. TANK DESCRIPTION - COMPLETE ALL |TEK8G ' IF UNKNOWN - S{} SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7089). B. Indicate the name ofthe company that manufactured the tank(ex.ACME TANK K0FG). O. Indicate the year the tank was installed (ex. 1B87). D. Indicate the tank capacity ingallons(ex.2G.000o/1D.DOOe0cj. |i TANK CONTENTS A. 1. |F MOTOR VEHICLE FUEL,check box iand complete items B&[|. 2. Ifnot MOTOR VEHICLE FUEL,check the appropriate box insection Aand complete items B&D. B. Check the appropriate box. C. Check the type mfMOTOR VEHICLE FUEL(if box 1iachecked inA). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number).ifbox 1iaNOT checked inA. Ui TANK CONSTRUCTION ' MARK ONE ITEM ONLY IN BOX A. B. C 8 D 1Check only one item |nTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. UOTHER,print inthe space provided. |V. PIPING |WF(]RK8AT!{}N 1. Circle"A"if above ground circle"U"if underground,and circle both if applicable. 2. |fUNKNOWN circle;orifOTHER, print inspace 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 bocomply with the monitoring requirements for the tank. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED' MONTH/YEAR ,y. 1988nr01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check^Yes^or"No^. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE RJRk8 AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification b is composedofthe two 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(916)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 OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE P|NK �� SHOULD BE RETAINED BY THE TAN��N�/NER. ��