COMPLIANCE INFO_1997-2001 - Laserfiche WebLink

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0 0 INSTRUCTIONS FOR COMPLETING FORM "B' GENERAL INSTRUCTIONS ' ' Section 271 1ofTit�'e23, Division 3. Chapter 16, California Code ofRegulations and sections 25286' 25287, and 2528Q of ChapterG7, Division 2U. Health and Safety Code require tank owners toapply for anLIST operating permit, 1. One FORM "B"nhoUbecompleted fo each tank for || NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/oran 1hINFORMATION E 2. This form shou|dbe completedbyeidher1bePERKX}TAPPL(CANTordhoLOCALAGENCYUNDER' GROUNDTANK |NSPEC7{}R. 3. Please type nrprint clearly all requested information. 4. Use ahard point writing instrument, you are making 3 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]. 8, Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTm[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1� Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2� Indicate the DBA or Facility name where the tank is installed. |. TANK DESCRIPTION - COMPLETE ALL ITEMS ' IF UNKNOWN - GO SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7078Q\ B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1907). D. indicate the tank capacity|ngallons (ex.25.DU0nr10'ODOetc,). ||. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1 and complete ibamsB&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 iochecked inA). D� Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#, (Chemical Abstract Service numbar). |/box 1 iaNOT checked in& |U. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D 1Check only one item inTYPE{]FSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2, KOTHER, print inthe space provided. ^ |V. PIPING INFORMATION 1� Circle"A" ifabove if underground, and circleboth if applicable. 2L KUNKNOWN circle; orit OTHER, print inspace provided. 1 Indicate the LEAK DETECTION syotem(s) used bzcomply with the monitoring requinamentfordhepiping. . . . V. TANK LEAK DETECTION 1. Indicate 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 MONTH/YEAR or 01/88) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remoininginthe tank (in GaUons). 1 WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER DR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AG INDI- CATED [see section 2711 (a)/13\ CCRl INSTRUCTION FOR THE LOCAL AGENCIES The state underground ototank identification b 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"'form "A . The tank number may~"assigned~xthe local agency,however,this number'"~"`°e''~^~^~~~'~ cannot contain analphabet. If the local agency prefers the State Board toassign the tank number,please leave bblank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION, THE LOCAL A{�ENOY IS RESPONSIBLE FOR THE CDK�PLET}�2N OF THE �� ^b� ALA6ENCY USEONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE'ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER.