COMPLIANCE INFO_1997-2001 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL |NSTRUOT|C)N8 Section 2711 cfTble 23 Division 3, Chapter 18. California Code ofRegulations and sections 2528G,25287, and 25289 ��aptler8J. Division 20, Health and Safety Code require tank owners to apply for an UST operating permit, 1, One FORM,"B"shall becompleted for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2, This form should bocompleted byeitherthePERK8|TAPPL|CANTortheLOCALAGENOYUNDEB' GROUNDTANK |NSPECTOR, 8, Please type orprint clearly all requested information. 4. Use ahard 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 tobuildings and landmarks[2711 (a)(8)CCR], & Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(11) CCR], TOP OF FORM: K8/\RK ONLY ONE ITEM 1. Mark an (X)inthe box next tothe item that best describes the reason the form iebeing completed. 2� Indicate the DBA or Facility name where the tank ioinstalled. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - 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. AB7O7BQ)� B� Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG). Q. Indicate the year the tank was installed (ex. 1887). D. Indicate the tank capacity ingallons(ex. 25.000ur10,000eto,). |L 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 1 ischecked inA). D, Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number). Jbox 1 iaNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN 8(]X A' B' C & D 1Check only one item inTYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, 2. |fOTHER, print inthe space provided. K( PIPING INFORMATION 1, Circle"A" Kabove groundcircle 1U" if underground, and circle both if applicable, 2. KUNKNOWN circle; oritOTHER, print inspace provided. ' 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. Vi INFORMATION ON TANK PERMANENTLY CLOSED /N PLACE 1. ESTIMATED DATE LAST USED-M{}NTH/YEAR 1/38) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining�n 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 h;eg section 2711 /e6(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number,the thre4 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 8DX' THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND > YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER.