COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FRI "B" GENERAL INSTRUCTION Section 2711 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25266, 25257,and 25239 of Chapter 6.7,Division 20, Health and Safety Code require tank owners to apply for ars LIST operating permit, 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHA S, I EMOV. 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 NDER- OUND TANK INSPECTOR. _ _ . Please type or print clearly all requested information, 4. Use a hard point writing instrument,you are making 3 copies. 5. Tank owners st submit a plot plan to the local agency showing the location of-the LISTSwith respect to buildings and landmarks(2711 (a)(S)CCR], . Tank owners must submit documentation showing compliance with state financial resp,:i!zb ility require- ments to the local agency for petroleum USTs[2711 (a)(11)CCR]. TOR OF FOR ARK ONLY ONE ITE 1. Mark an(X) in the box next tdirie.item that best cleg6ribes the reason the form is bei . Indicate the DBA or Facility name-where the tank is installed, I. TANK DESCRIPTION ® COMPLETE ALL ITEMS a IFC KN a SO SPECIFY' A. Indicate owners tank ID#-If there is e tank number that is used by the owner to idea (ex. A7769). Indicate the name of the company that manufactured the tank(ex.ACME TANK `a a: C. Indicate the year the tank was installed(ex. 1937). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). II. 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 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 tank and the C.A.S. . (Chemical Abstract Service number),if box 1 .is NOT checked in A. III. TANK CONSTRUCTION$DARK ONE ITEM ONLY IN BOX A, R, C & D 1.-:- Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING aJ CORROSION PROTECTION. . If OTHER, print in the space provided, IV. PIPING INFORMATION 1, Circle`°A"if above ground circle"U"if underground,and circle oth if applicable; 2. If UNKNOWN circle;or if OTHER, print in space provided. . 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 co ply with the monitoring requirements for the tank. Vl. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE _ a 1. ESTIMATED DATE LAST USED'® MONTHNEAR(January, 1933 or CII?33) . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), . WAS TANK FILLED WITH INERTMATERIAL? 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 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) 7-4303. The facility number must be the same as shun in form-'%". The tank nurse 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 teak number, please leave it blank. IT IS THS 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 DISE ONLY" INFORMATION BOX. TETE LOCAL AGENCY SHOULD DETAIN THE ORIGINAL AND YELLOW COPIES. THE KINK C , SHOULD BE RETAINED BY THE TANK NER. ,I