COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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Ask INSTRUCTIONS FOR COMPLETING FORM B" OENERAL AL_ INST UCTI N Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25286, 25267,and 25289 of Ch pt r 6.7,Division ion 2 , Health and Safety Cade require tank owners to apply for an LIST operating permit. 1. One F R T" lull be completed for each tankfor alt.N W PERMITS, PERMIT"CHANGES, REMOVI ;. ALS adior any other TANK INFORMATION CHANGE. 2. This form should be completed by ether the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. . Please type or print clearly all requested 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 showingthe location of the USTs with respect to buildings and landmarks(9711 (a ( )CCR). . Tank owners must submit documentation showing;compliance with state'financial re pnix inility require- ments to the local agency for petroleum USTs 12711 (a)(11)CCAj # TOP OF FOS MARK ONLY ONE ITS 1. rk:ah(X)in'the box next to the item that best describes e reason the fo rm is be, b , 2. Indicate.the DPA or facility name where the tank it installed. 1. TANK DESCRIPTION - COMPLETE ALL IT - I P l .r,; . Indicate owners tank ID -I there i a tank number that is u bythe owner to id t,;;` (e$ A 70789). B. Indicate the name of the company that manufactured t ee n (ex.ACMETANK MFG,i, C. Indicate the year thtank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,0 t .). IL TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL,check box I and complete item 2. If not MOTOR VEHICLE L,chock the appropriate box in section A and compete iterns S&D., B. Check the appropriate box. C. Check the type of MOTOR VEHICLEF! (if box 1 is,checked in.A). D. Print the chemical name of the hazardous substance stored in thitank and the C.A.S. . (Chemical Abstract Service number), if box 1.18 NOT checked in A. Ill. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, 1. Check only one item in TYPE 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.: . If UNKNOWN circle;or if OTHER,print in apace provided. 3. Indicate the LEAK DETECT16N system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAKDETECTION system(s)used to cotriply with 1he monitoring requirements for the tank, Ula INFORMATION ON TANK PERMANENTLY CL SED IN PLACE 1. ESTIMATED DATA LAST USE -MONTHNEAR(January, 1988,or 01! ) 2. ESTIMATED QUANTITY of HAZARDOUS SIJ STANCE remaining in the tank(In Gallons). . WAS TANK FILLED WITH INERT MATERIAL? C "'Yo "or"No". TANK OWNERAUTHORIZED F TA IU UST SIGN A [BATF THE FORM AS INDI- CATED, I-CATER, [see section 2711 (4)(13)CCRI INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the b digit county number,the three digit iri diction number,the six digit facility number and;tf e,six digit tank number. The county and jurisdidtion numbers are predetermined and can be obtained by calling the State Board(91,6)227-4303. The facility member must be the 'same as shorn in form"A". The tank number may be assigned by the local agency,ho dv r,this number must bo numerical and cannot contain an alphabet. If the local agency prefdra the Mata Board to assign the tank number, please leave it blank.' IT IS THE RESPONSIBILITY OF TIFF LOCAL AGENCY THAT INSPECTS THE A ILI TO VERIFY THE ACCU- RACY t1- RA Y F THE INFORMATION. This LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION SOX. THE LOCAL AGENCY SHOULD RETAIN TH15 I INAL AND YELLOW COPIES. .THE PINI{ Y SHOUILD BE RETAINED BY THE TANK ., NE .