COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 2 , Division 3,Chapter 1 , California Cade of Regulations and sections 25266,25257, and 25259 of Chapter 6.7, Division 2 , Health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMAT*N 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 e6qu6sted information. ' 4. Use a hard point writing instrument, you are.making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings.acid androarks [2711 (a)(0)CCP]. 6. Tarek owners must submit documentation showing compliance with state financial responsibility require- ments to the foal agency for petroleum USTs[2711 (a)(11) CSR]; TOP OF O AHK ONLY ONE ITE 1. Mark an (X) in the box next to ttie item that best describes the reason the form is being completed. - 2. Indicate the DBA or Facility name where the tankai installed. I, TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOW - SO SPECIFY A. Indicate owners tank ID - If there is a tank number that is used by the owner to identify the tank(ex. AB70769). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG), C. Indicate the year the tank was installed (ex. 1937). D. Indicate the tank capacity in gallons(ex.25,000 or 10,040 etc.). II. TANK CONTENTS 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 complete items B&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 name 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. III. TANK CONSTRUCTION.- MARK ONE ITEM ONLY 1N SOX A, B, C & D 1., Check only one item in PE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A" if above ground circle"U" if underground, and circle both if applicable. 2. 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. Indicate the LEAK DETECTION ystem(s)used to comply ly with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- IONTHNEAR (January, 1933 or 01/68)' 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), & 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 storage tank identification number is composed of the=two digit county number,the three digit juris . tion number,the six digit faciitlty number,and-the six digit-ta k number: `file county and jddidiction 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 cogtain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS T4 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 COPY SHOULD BE RETAINED BY THE TANK OWNER.