COMPLIANCE INFO_1986-2001 - 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, 25267, 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 e h;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, ro 31 Plean-type or print clearly all requested infcarrnation. 4. Use a hard point writing instrument,you are.making 3 copies. . Tank owners must submit a prat plan to the local agency showing the location of the I..TSTs with respect to buildings and landmarks(2711 (a)(3) CCR]. 6. Tank ogler €gust submit documentation showing compliance with stat;finariclal responsibility require- ments to the local agency for petroleum USTs(2711 (a)(11) C R], TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describes the reason the fora is being completed, 2. Indicate the IDEA or Facility name where the tarok is installed. 1. TANK DESCRIPTION - COMPLETE ALL ITEMS _ IF UNKNOWN - SO SPECIFY A. Indicate owners tank ICS #- If there is a tank number that is used by the towner to identify the tank(ex. AE707S9). R. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). , Indicate the year the tank was installed (ex, '1967). . Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc,), IL TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box. 1 and complete items B&C. , If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items R&D. B. 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 - MARK ONE ITEM ONLY IN BOX A, S, C & D - 1. 'beck only one item in TYPE OF SYSTEM, TANK gATERIAL, INTE fIIOR LIVING and CORROSION PROTECTION. 2. If OTHER, print in the space provided. lvI PIPING INFORMATION �. 1. Circle"A`°if above ground circle "U" if underground, and circle bath if applicable. . If UNKNOWN dircle; 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 N 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. V1. INFORMATION ON TANK PERMANENTLY CLOSED 3 IN PLACE 1, ESTIMATED DATE LAST USED., MONTH/YEAR (January, 1936 or 01!63) . 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 TATIVE UST" SIGN ANIS DATE THE FORM AS INDI- CATED ATE£ [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 y calling the State Board(916)22`7-4303. The facility number must be the same as shown in form"A". The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the Mate ward to assign the tank number, please leave it blank, IT dS THE,RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY U- RA Y OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY„ INFORMATION N CSX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE FINK C(dh,SHOULD BE RETAINED BY THE TANKNER,