COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPONG FORM ^B" GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division 8. Chapter 1O. California Code ofRegulations and sections 2528G. 25287. and 252GQ of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. 1. One FORM ^B^ shall becompleted fDr each tankf NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should bcompleted 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 3copies. 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]. 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 QFFORM: 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 ieinstalled. |' 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. AB70788). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C. Indicate the year the tank was installed (ax. 1QG7). � D. Indicate the tank capacity(ngallons(ex. 25.OUOor1O.ODUet l. ||' TANK CONTENTS A. 1. |FK8DTORVEHICLE FUEL, check box 1and complete items B&[�. 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). O. Print the chemical name ofthe hazardous substance stored inthe tank and the C.A.G.#. (Chemical Abstract Service numbeh. i/box 1ioNOT checked inA. |||. TANK CONSTRUCTION ' MARK ONE ITEM ONLY IN BOX A, B. C & O 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 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 oys1em(s) used bocomply with the monitoring requirements for the tank. \/|. INFORMATION ONTANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR nuary. iQ8BorO1/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check^Yea"or"No". ` TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (o)(13) CCR' INSTRUCTION FOR THE LOCAL AGENCIES The ote1a undergroundstonu e tank identification number incomposed ofthe 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 shown inform"A^. The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain analphabet. Uthe local agency prefers the State Board 0oassign the tank number,please leave bb|ank IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGEN��Y 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. �� `�