COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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�--------------��--7,`-- -----�'---�----� -- ------' INSTRUCTIONS FOR COMPLETING FORM 013" GENERAL INSTRUCTIONS Section 2711of Title 23.Division 3.Chapter 16 Cali Code of Regulations and sections 25286,25287.and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to.apply for anLIST operating permit. 1. One FORM "B"shall becompleted forea: tank for all NEW -PERMITS, PERMIT CHANGES, REMOV- ALS and/or an EMOV- AL8and/oran other TANK INFORMATION CHANGE. ' 2 This form should becompleted byeither the PERMIT Torthe LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 1 Please type or printclearly U requested information. - Use - hard point writing instrument, you are making _ 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. O. Tank owners must submit documentation showing compliance with state financial responsibility require- ments tothelooa|agenoyforPetm|eumUSTs [2711 (a)(1 1) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1� Mark en(X)inthe box next 8othe item that best describes the reason the form imbeing completed. 2. Indicate the DBA or Facility name where the tank is installed. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN ' SO SPECIFY A. Indicate owners tank |D#-Kthere isatank number that is used by the owner to identify the tank (ex. A B. Indicate the name ofthe company that manufactured the tank (eu ACME TANK K0FG). C. Indicate the year the tank was installed (ew.1A87). D. Indicate the tank capacity ingallons (ex.25.00Uor1Q.O0Oetc.). U. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and complete kmn C. 2. |fnctKAOTORVEH|CLEFUEL.checbthemppnzpKa1ahoxinmectionAandcomp|eteUomsB&D. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL (if box 1iochecked inA). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number).ifbox 1 isNOT checked |nA. Ui TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B. C & [> ' 1. Check only one item inTYPE OFSYSTEM, TANKMA7ERIALINTERIOR LINING and CORROSION PROTECTION. -- - 2. IfOTHER, print inthe space provided. |V. PIPING INFORMATION 1. Circle "A" if above ground circle "U" if underground, and circle both if applicable. 2. |fUNKNOWN circle; orifOTHER, 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|. \NFC}RK4AT|C}N ON TANK PERMANENTLY CLOSED IN PLACE ` 1. ESTIMATED DATE LAST USED 'KXONTH/YEA nue/y.108Bnr01/88 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining inthe tank (in Ga||ons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yoe"o,"No". TANK OWNER ORAUTHORIZED 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 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 THATlNSPBCTSTHE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USEONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK CC6 SHOULD BE RETAINED BY THE TANK # NER.