COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "E3" GENERAL INSTRUCTIONS Section 2.711 of Title 28, Division 3, Chap f 1- Morn? Code of Regulations and sections 26286, 25287, and 26289 of Chapter 6.7, Division 20,Health and Safety Coce`req'uir6 tank owners to apply for an LIST operating permit. 1: One FORM "B"shall be completed for each tank for all NEW PERMIT PERMIT CHANGES, REMOV- ALS andfoT any ether TANK INFORMATION CHANGE, 2. This fora}should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UN C-R� GROUND TANK INSPECTOR: 3. Tease type or print Nearly all requested information.j 4, Use a hard point writing instrument,you are making 3 copies. 6. 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)(8)COR]. 6. Tank owners must submit documentation showing(�brnipliance with'state,financial responsibility require- ments to the local agency for petroleum USTs(2713 (a)(11) CCRI, TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describesthe reason the form is being completed. 2. Indicate the IBA or Facility name where the tank is installed. i. TANK DESCRIPTION - COMPLETE .ALL ITEMS - 1F UNKNOWN - SCS SPECIFY A. Indicate owners tank I - If there is a tank number that is used by the owner to identify the tank(ex. A79789). 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 19.999 eta.). If. 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 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, 3, C & C 1:^ -,heck only one item in TYPE OF S` STEM,'TANK N,' TERIAL. INTERIOR LINING and CORROSION PROTECTION, 2. If OTHER, print in the space provided. IV. PIPING INFORMATION 1. If6le"A"if above ground enrol "f "€f tinderground, 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 LEAD DETECTION system(s)used to comply with the monitoring requirements for the tank., VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED a MONTH/YEAR (January, 1988 or 931£18) 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 NTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED (see section 2711 (a)(1 S) CCT INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tarok identification number is composedI of the two digit county number,the three digit jurisdiction 66 Ei r,the six digit facility n mb f hd the ix digit tank number, The county and jurisdiction l b rs are predetermined and can be obtained by calling the State Board (916)227-430 . 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 Board 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 THE "LOCAL AGENCY USE ONLY" INF, MATION BOX, THE LOCAL. AGENCY SHDETAIN THE ORIGINAL AND YELLOW COPIES. THE P#NK C SHOULD BE RETAINED BY THE TANK jjPNER.