COMPLIANCE INFO_1985-2000 - Laserfiche WebLink

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-- ~ INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 ofTitle 23. Division 3. Chapter 1G. California Code ofRegulations and sections 25288.25287. and 2528S of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or anyother TANK INFORMATION CHANGE, ' 2� This form should becompleted byeitherdhePERK4|TAPPL|CANTnrtheLOCALA(�ENCYUNDER- - GROUNDTANKIN8PECTOR. 3. Please type orprint clearly all requested information. ' 4. Use ahard point writing instrument, you are making 3copies. 5. Tank owners must submit aplot plan tothe local agency showing the location ofthe USTowith respect \obuildings and landmarks [2711 (a)(8)CCR]. -6 Tank owners must submit documentation showing compliance with state financial responsibility require- ments,tothe|uoa|agenoyforpetoo|eumUSTe[2711 (a)(11)-CCR]. ' TOP OF FORM: K4AflK ONLY ONE ITEM 1. Mark an (X) 'n the box next t�the item that best describes the reason the form is being completed. 2. Indicate the �BAorFacility namewhere the tank is installed. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - G(] SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78Q). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C. Indicate the year the tank was installed (ew. 1987). D. Indicate the tank capacity ingallons (ex. 25.000or10.000e\cj. ' U. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box and complete items B&C. 2. |fnot MOTOR VEHICLE FUEL,check the appropriate box insection Aand complete items B&[>. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL(if box 1 ischecked inA). O. Print the chemical name of the hazardous substance stored inthe tank and the CA.S.#. (Chemical Abstract Service number). ifbox 1 iaNOT checked inA. ' ||!. TANK CONSTRUCTION~ MARK ONE ITEM ONLY IN BOX A, B' C & D Check only one item inTYPE{}FSYSTEM,TANK_MATERIAL, INTERIOR LINING and CORROSION PROTECTION. '-2. |fOTHER, print inthe space provided. |V. P|PiNG INFORMATION 1, Circle "A" if above ground circle"U^ ifunderground, andcirdebothifepp|icab|e. 2. |fUNKNOWN circle; ori<OTHER, 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 thoLEAKDETEOTON — (s)used bocomply with the monitoring requirements for the tank. V!. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- K4[)NTHy/EAR nuary. 1A88or01/88) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining|nthe tank (in GaHona). 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yea"nr"No". - ^ TANK OWNER ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (e)(73) CCR] ` INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification numb is composed ofth two digit county number,the three digit jurisdiction number,the six digit facility number and the six digit tank number. The.county and�irigdiction-numbers are predetermined and can_ obtained-' calling the State Board `- -'-_ -'- facility' number shown inform "A"' The tank number may beassigned bythe local agency,however,this number must benumerical and cannot contain enalphabet. 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 [V�ft SHOULD BE RETAINED BYTHE TANKNER. ��k