COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

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Y "��. INSTRUCTIONS FOR COMATING FORM "B" GENERAL INSTRUCTIONS Section 2711 ofTitle 23. Division 3. Chapter 1G. California Code ofRegulations and sections 2528S' 2G287. and 25280 of Chapter 6.7, Division 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 completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. | 3. Please type orprint clearly all requested information. 4. Use ahard point writing instrument, you are making 3 copies. 5. Tank owners must submit o plot plan to the local agency showing the location of the USTs with respect tobuildings and landmarks (a)(8)CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- mentstothe|oca|agenoyforpetno|eumUGTo[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 io installed. |. TANK DESCRIPTION - COMPLETE ALL |TEK88 ' IF UNKNOWN ' SC} SPECIFY A. Indicate owners tank ID #- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78Q). B. Indicate the name ofthe company that manufactured the tank(ex. ACME TANK MF8). C. Indicate the year the tank was installed (au. 1987). D. Indicate the tank capacity ingallons (ex. 25.00Oor1U.08Oeb:j. ||. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and complete i8amo8&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. B. Check the appropriate bnx. C. Check the type ofMOTOR VEHICLE FUEL(if box 1 iochecked-in A). O. Print the chemical name ofthe hazardous substance stored inthe tank and the C.A.G.#. (Chemical Abstract Service number)' ifbox 1 ieNOT checked inA. |||' TANK CONSTRUCTION ' MARK ONE ITEM ONLY IN BOX A' B. C & D 1. Check only one item inTYPE{]FSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print|nthe space provided. |V. PIPING INFORMATION 1. Circle"A" ifabove ground circle "U"ifunderground,and circle both ifapplicable. 2. |fUNKNOWN 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- MONTHNEAR (January, 1988or01/88) D. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in 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 [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification numberi 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 BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BYTHE TANK OWNER. 0