COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

Home Browse Search

0 INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL AL INSTRUCTIONG Section 2711 of Title 23, Division 3,Chapter 15, California Code of Regulations and sections 25230,25237,and 25289 of Chapter 5.7, Division 20, Health and Safety Code require tank owners to apply for ars LIS") operating permit, 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANCES, 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 NC TANK INSPECTOR. 1 Please type or print clearly all requested information; 4, Use a hard point writing instrument,you ara making 3 copies. 5. Tarek owners roust submit a plot plan to the local agency showing the location of the USTS.wth respect to buildings and landmarks[2711 (a)(&)CCR]. 5. Tank owners roust submit documentation showing compliance with state financial respr< .�bllity require- ments to the local agency for petroleum t1STs[2711 (a)(11)CCP]. TOP OF FORM: MARK ONLY ONE ITE 1. Mark` n (X) in the box next to the item that best describes the reason the form is be,' ;.# . Indicate the DBA or Facility name where the tank is installed. I, TANK DESCRIPTION ® COMPLETE ALL ITEMS a IF UNKNOWN KN - SO SPECIFY A. Indicate owners tank ID#-If there is a tank number that is used by the owner to lder :. _: . (ex. AB70789). Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG a. C. Indicate the year the tank was installed(ex. 1937). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.); 11. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and comps-te itern C. 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]s NOT checked in A. III. TANK CONSTRUCTION 6 MARK ONE ITEM ONLY IN BOX A, B, 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. w IV. PIPING INFORMATION Circle"A"if above ground circle"U"if underground, and circl both if applicable, . 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 DEttCTION 1, Indicate the LEAK DETECTION system(s)used to comply'with the monitoring requirements for the tank. V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED® MONTHLY R(January, 1988 or 01f88) 2. ESTIMATES QUANTITY of HAZARDOUS SUBSTANCE remaining in`the tank(in Gallons). . WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM ASINDI- CATED [see section 2711 (a)(1 ) CCR] ... INSTRUCTION FOR THE LOCAL AECES The state underground storage tank ntifie i ry rymb60bnTpo ad of the two digit county number,the three digit jurisdiction number,the six digit facility er and Ike six nk number. The county and Jurisdiction numbers are „ predetermined and can be obtained by calling the State Board(916) 7-430& The facility number must be the carne as shoe In fora"A". The tank numbed, . be assigned by the localagency,however,this number must be numerical and cannot contain a Ip abet. ,If:the loyal a qcy prefers-toe State . and to assign to tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCt1- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD AIN THE ORIGINAL AND YELLOW COPIES, THE PINI{ C# SHOULD 6E RETAINED BY THE TAN NEP.