COMPLIANCE INFO_1985-2000 - Laserfiche WebLink

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_ . INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 2528G.25287.and 2528S cfChapter 6.7' Division 20. Health and Safety Code require tank owners toapply for an LIST operating permit. 1. One FORM "B" shall bocompleted for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should becompleted byei\har1hePER@|TAPPL|CANTorihoUOCALA(3ENCYUNDER- GRDUNDTANK |NGPECT{}R. 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 tothe local agency showing the location ofthe USTowith respect to buildings and ld ks (a)(8) CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments tothe local agency for petroleum USTs[2711 (a)(11) CCR]. TOP OF R]RK8: MARK ONLY ONE ITEM 1. Mark an (X) [n the box next to the item that best describes the us000n the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. |. TANK DESCRIPTION ' COMPLETE ALL |TEK88 ' IF UNKNOWN - 8O SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78g). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C Indicate the year the tank was installed (ez. 1087). O. Indicate the tank capacity ingallons (ex.25.UOOor10.U00e1c.). |i 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. O. Check the type ofMOTOR VEHICLE FUEL(if box 1 iechecked inA). D. Print the chemical name of the hazardous substance stoned in the tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1 imNOT checked inA. )||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & [} 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print inthe space provided. |V. PIPING |NFDF\K4AT|DN 1. Circle "A" if above ground circle"U"if underground, and circle both if applicable. 2. |fUNKNOWN circle; orJOTHER, 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|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED ' k4ONTH/YEAR nuary. 1A88orO108) 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 FORM AS INDI- CATED (see section 2711 (a)(13) CCR] ' INSTRUCTION FOR THE LOCAL AGENCIES The state underground sto tank idntifioad be 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 PINK Co SHOULD BE RETAINED BYTHE TAN �� NER. �� _