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, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Cade require tank owners to apply for an UST operating permit. 1. One FOI "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any ether TANK INFORMATION CHANGE, 2. This farm should be completed by either the PERMIT APPLICANT or the LOCAL.AGENCY UNDER- GROUND N rE - GROUND TANK INSPECTOR, 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 plat plan to the local agency showing the location of tha LISTS with respect to buildings and landmarks (2711 (a)(8) CCR). 6. Tank owners must submit documentation showing compliance with state financial responsibility require- gents to the local agency for petroleum LISTS [2711 (a)(11) CCR), TOP OF FORD: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. . TANK DESCRIPTION m COMPLETE ALL ITEMS - IF UNKNOWN m SO SPECIFY A. Indicate owners tank 17#- If there is a tank number that is used by the owner to identify the tank (ex, AB7O789). 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 107,099 etc.). IL TAMC CONTENTS A. 1. IF MOOR 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. 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 stared in the tank 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, R, C & D 1:, - Check only one item in TYPE OF SYSTEM,TAW+rATERIAL, INTERIOR LINING and CORROSION PROTECTION, 2. If OTHER, print in the space provided. lv. PIPING INFORMATION 1. Circle" " if above ground circle"U" if underground, and circle bath 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 systems)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED w MONTH/YEAR(January, 1988 or 071188) 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 LDATE.,THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] ' t INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county member,the three digit jurisdiction number,the six digit facility number and the six digit tank n'u'm6er.' The county and jurisdiction numbers are predetermined and can be obtained by calling the Mate Board(916)227-4303. 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 State Boars)to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE AGODU- RACY OF THE INFORMATION, THE LOCAL AGENCY 1S RESPONSIBLE FOR, THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INF RMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLCO COPIES, THE PINI[ C SHOULD BE RETAINED BY THE TANKi ER.