COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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Pt t t INSTRUCTIONS FOR COMPLETING PCR r1 "B" GENERAL INSTRUCTIONS L� Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25256, 25237, and 25252 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST"operating permit. 1. One FORE; „S„shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES,S, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This farm should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information, 4. Use a hard point writing instrument, you are making 3 copies. . 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)(6)CCR]. 6. Tank owners must submit documentation shoeing compliance with state financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(11) CCR], TCP CP FORM: MARK ONLY ONE ITEM 1. Mark an O in the box next to..the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility nerve where the tank'is installed, 1. TANTO DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SCJ SPECIFY A. indicate owners tank ID f#- If there is a tank number that is used by the owner to identify the tank(ex. x,575769). B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MPG), C. Indicate the year the tank was installed(ex. 1987). I. Indicate the tank capacity in gallons (ex.25,633 or-1 0,000 etc.). IL TANK CONTENTS A. 1. IF MOTOR VEHICLE PIXEL, 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&S. S. Check the appropriate box. C. Check the type of MOTOR VEHICLE PLISL(if box 1 is checked in ). D. Print the chemical name of the hazardous substance stared in the tank and the C.x;.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 & 1 1. Check only one item In TYPE CSP 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 circle bath if applicable. 2. It 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 system(s)used to comply with the monitoring requirements for the tank. I. INFORMATION 3 TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ?ATE LAST USED .m.MO THIYSAR (January; 1555 or 61166) 2. ESTIMATED QUANTITY of HAZARDOUS SUB T NCE remaining in the tank (in Gallons). 1 WAS TANK FILLED WITH INERT MATERIAL? Check"Yes„or"No", TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DTE THE FORM AS INDI- CATED ` CI-CATER [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 nu rs er,the six digit facility number and the six digit tank number.,T"he county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (316)227-4303. The facility number must be the same as shown in form "A". The tank number may be assigned by the Racal agency,however,this number must be numerical and oar t eat contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY CP THE LC AL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY CComR ,CY CP THE INFORMATION, THS LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION CP THE "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK C S!-OUL RE l T II ED BY THE TANK NER.