COMPLIANCE INFO_1997-2001 - Laserfiche WebLink

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- . 0 0 INSTRUCTIONS FOR COMPLETING FORM "B^ GENERAL INSTRUCTIONS ' Section 2711ofTlUe23. Division 3. Chapter 16, California Code ofRegulations and sections 2G286,25287, and 2528Q of Chapter 6,7, D'Nision 20, Health and Safety Code require tank owners to apply for an LIST 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 be completedbyeither#haPERKX|T/\PPUCANTortheLDCALAGENCYUNOER' GRC}UWQTANK|NSPECTC)R. 3, Please type orprint clearly all requested information. 4, Use ahard point writing instrument, you are making 3 copies. 5� Tank owners must submit aplot plan to the local agency showing the location ofthe U6Towith respect to buildings and landmarks [2711 CCR1. G� 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: 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 orFacility name where the tank is installed. i TANK DESCRIPTION - COMPLETE ALL ITEMS ' IF UNKNOWN - 8O SPECIFY A. Indicate owners tank ID#- It 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 (ex. 1S87). D. Indicate the tank capacity/ngallons(ex. 2S.V0Oor1O.00Oeto.). IL TANK CONTENTS A. 1, |FMOTOR 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 ofMOTOR VEHICLE FUEL(if box 1ischecked|nA). O� Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number). iYbox 1ioNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B' C & D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print inthe space provided. |V. PIPING INFORMATION 1� Circle"A" if both if applicable. 2. UUNKNOWN circle; orif 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 the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- C) H8' (January, 2. EBT|K4ATED[]UANT|TYofHAZARDDUSSUBSTANCEmmainingin1hebank (inGaUono). 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER DRAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORMAS INDI- CATED [see section 2711 (a)(13) CC R] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification b is composedo|the two digit countynumber,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 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 VER|FYTHE 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 BYTHE TANK OWNER.