COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" 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 UST 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 µ 3. 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 focal agency showing the location of the LISTS with respect to buildings.and landmarks(2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing compliance With state financial responsibility require- vents to the local agency for petroleum LFTs [2711 (a)( 1) CCI], TCP OF FORM: DARK ONLY ONE ITEM 1. Mark an (X) in the box next to the,item that best describes the reason the form is being completed, , Indicate the IDSA pr facility name where the tank is installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SCS SPECIFY A. Indicate owners tank ICS # If there is a tank number that is used by the owner to identify the tank(ex. A670789). S. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). C. Indicate the year the tank was Installed (ex. 1937). D. Indicate the tank capacity In gallons (ex. 25,000 or 13,669 etc.), !L TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items R&C, 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items S&D. B, Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 Is checked in A�. D3 Print the chemical name of the hazardous substance stored in the�arik and the C.A.S. . (Chemical Abstract Service number), if box 1 Is NOT checked in A. Ill. TANK CONSTRUCTION N - MARK ONE ITEM ONLY IN BOX A, R, C & D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LIPPING and CORROSION PROTECTION. ORRO ION PROTECTION. 2, If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A" if above ground circle"Li" if underground, and circle both if applicable. 2. If UNKNOWN-circle; or if OTHER, print In space 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 syst m(s)used to corn l rwith the monitoring requirements for the tank. VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i. ESTIMATED LATE LAST USED- INTHIYEAR (January, 1588 or 01/88) . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check"YesB4 or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED (see section 2711 (a)(1 ) CORI INSTRUCTION FOR TIE 'LOCAL AGENCIES i The state underground storage tank identification number to 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 y calling the State Board(91 6)227-4303. The facility number mint be the same as shown in form"A=", The tank number may be assigned by the localagency,however,this number must be numerical and cannot contain an alphabet. If the local agency,prefers the State Shard 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 TIME "LOCAL AGENCY USE ONLYY" INF ATION BOX. THE LOCAL AGENCY SH U DETAIN THE ORIGINAL ANIS YELLOW COPIES. THE: PINK C SHOULD BE RETAINED BY THE TANK ER;