COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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E 11 GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California 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 an LIST operating permit, 1 One FORM "B" shall be completed 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, 1 Please type or print clearly all requested Information, 4. Use a hard point writing instrument, you are making 3 copies. 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], 1 6, 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 t6 the item that best desicribes the reason the form is being completed.. 2. Indicate the DBA or Facility name where the tank is'installed. E. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # ® If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG), C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). Ill. TANK CONTENTS A. 1. IF MOTOR 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. S. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the, lank and the C.A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. Ill. 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. If OTHER, print in the space provided. IV. PIPING INFORMATION 1, Circle "A" if above ground circle "U" if underground, and cirqte,both if applicable, 2. If UNKNOWN circle; or if OTHER, print in space provided, 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1 Indicate the LEAK—RETETIONstern(s) used to cQmRly with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED7=_,MONTH/YEAR (January, 1988 or 01/881 2. 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] �NSTRUCTION FOR THE LOCAL AGENCIE9 I.. The state underground storage tank identification numberis 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 ar predetermined and can be obtained by calling the State Board (916) sh227-4303. The facility number must be the same as own infdrmlA". The tank nurrIb!M m, gy be assigned by the local agency however, this number must be numerical an cannot contaiman alphabet. If the(S�al agency prefers the State Board to assign the lank number, please leave it blank. I IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE -FACILITY TO VERIFY THE ACC Jvt� f-;.%ACWOF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE 'i1L6tAL* AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL A YELLOW COPIES. THE PINK SHOULD BE RETAINED BY THE TANJdhNNER,