COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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,INSTRUCTIONSFOR COMPLETING FORM "B" ENERAL. INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16,California' ode of Regulations and sections 25286, 25287,and 25289 of Chapter 61, Division 20,Health and Safety Code require tank owners to apply for an LIST operating permit. I, One FORM "B" shall be completed for aacl�tank for all NEW PERMITS, PERMIT CHANGES, REMOVi ALS and/or any other TANK INFORMATION GRANGE, 2. This fora should be completed by either the PERMIT"APPLICANT or the LOCAL.AGENCYVNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information, 4. Use a'hard paint writing instrument,you are making 3 copies. 5. Tank,owners must submit a plot plait to the local agency showing the location of the LF Ts-with respect to buildings and landmarks[271 11 (a)(6)CCP]. 6. Tank owners must submit documentation snowing compliance with state financial resp -, slbi,ity require- ments to the local agency for petroleum LI Ts[2711 (a)(11)CCP]. TOP OF FORM: MARK ONLY ONE ITE 1. ark a ).,in box next to the item that best describes the reason the for. i be . Indicate the DBA or Facility name where the tank is installed. L TANK DESCRIPTION - COMPLETE ALL ITE IF UNKNOWN KN IF=i; A. Indicate owners tank I -If there is a tank number that is used by the owner to ide.w .' A7079). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK F a:, C. Indicate the year the tank was installed(ex. 1967).; C. Indicate the task capacity in gallons(ex.25,000 or 10,000 etc.). IL TANKCONTENTS A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and comp?ete items E&D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). D. Print the chemical tame of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service number),if box 1 is NOT checked in A. 111. TANK CONSTRUCTION HI MARK ONE ITEM ONLY IN BOX A, B, C & I 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. if OTHER, print in the apace prodded. I . PIPING INFORMATION 1. Circle"A"if above ground circle"U"if underground,and circle both if applicable. . 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. TANK: LEAK DETECTION 1. Indican the LEAK DETECTION system(s)used to comply with the monitoring requirements for the.tank. Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED®ATE LAST USED¢MONTH/YEAR(January➢1933 or ct1/ 6) 2. ESTIMATED UANT1 of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons)_ WAS TALK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED IZE REPRESENTATIVE MUST SIGN AND DATETHE FORM AS IN I- , GAT [sea section 2711 (a)(11 3) IAC ] INSTRUCTION FORTE LOCAL AGENCIES The state underground storage tank identification neat er is composed of the two digit county rium er,'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 callingthe State Board(916)` 7-4303..The facility number must be the same as shown in form"A". The tank number may be assigned by the local agency,however,this numbermust 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 RESPONSIBLE FOR THE COMPLETION F THE "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD AIN TIME ORIGINAL AND YELLOW COPIES. THE PINK 'f SHOULD 6E RETAINED THE TANIWNER.