COMPLIANCE INFO_1985-2000 - Laserfiche WebLink

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0 IN 7 STRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286,25287, and 252B9 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit, I. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks[2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(1 1)CCRj. 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 or Facility name where the tank is installed. i TANK DESCRIPTION - COMPLETE ALL ITEMS ' IF UNKNOWN - GO SPECIFY A. Indicate ownerstank |O #- Uthere is a tank number that is used by the owner to identify the tank (ex. B. Indicate the name ofthe company that manufactured the tank(em. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1AB7). D. Indicate the tank capacity ingallons (ex.25.00Oor1O.00Oetc.). ||. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and complete items B&C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B&D� B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL(if box 1iechecked inA). O. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number)' ifbox 1 ieNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B' C & D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. /fOTHER, print inthe space provided. ' |V. PIPING INFORMATION 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 to comply with the monitoring requirements for the tank. V|. |NFC)RK8AT|{}N ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- K4ONTH/YEAR nuary. 1988or01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yea"or^No''. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED (see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank iddfi ati b is composed of the 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 UFTHE 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 PINK Cif � �� SHOULD B� RETAINED BY TAN NER. | �� ��,