COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING F "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25237, and 25259 of Chapter 5.7, Division 23, health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FORM "B"shall be completed for each tank for all NEW ERS ITS, 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. 3. Please type or print clearly all requested information. 4, Use a hard paint writing instrument,you are making 3 copies. . Tank owners must submit a plat plan to the local agency showing the location of the LISTS with respect to buildings and landmarks[2711 (a)(3)CCR), 6. Tank owners must submit documentation showing compliance with Mate financial resp€ ,L.1lity require- ments to the Incl agency for petroleum USTs[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITE 1. Mark an ( ) in the box next to the item that best describes the reason the form is bit 2. Indicate the DBA or Facility name where the tank is installed. i. TANK DESCRIPTION « COMPLETE ALL ITE m IF UNKNOWN SO SPECIF),' A. Indicate owners tank I ® If there is a tank number that is used by the owner to ides ( . A 70759). Indicate the name of the company that manufactured the tank(ex.`ACME TANK F&, C. Indicate the year the tank was installed (ex. 1957). D. 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 cornplot items B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and comp!(-Ie items 8&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. . , (Chemical Abstract Service number), if box 1]s NOT checked in A. III. TANK CONSTRUCTION _ MARK ONE ITEM ONLY IN BOX A, - 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, 2. if OTHER, print in the space provided, IV. PIPING INFORMATION . Circle"A"if above ground circle"U"if underground,and circle both if applicable, 2. If UNKNOWN circler or if OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. .x V. TANK LEAK DETECTION 1'a Indicate the LEAK DETECTION system(s)used to comply with the>monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED CATS LAST USE ONTHNEAR(January, 1933 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS U TA GE remaining in the tank(inGallons). 3. WAS TANK FILLED WITH INERTMATERIAL? Check"Yeses or"No". TANK OWNER OR. AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED N I-CATER [see section 2711 (a)(13) CCR) INSTRUCTION F THE LOCAL.AGEI G The state underground storage to identffioaiion cti tuber compo ' d of the two digit county number,°the three digit jurisdiction number,the six digit fdci er and the six d t rik•number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number must be the Barrie as shorn iii fa 'A". The tank number"may be assigned by the local agency,however,this number must be numerical and cannot containanalphabet, .If the local agency prefers the Mate Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF TETE 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" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK Y SHOULD E RETAINED BY THE TAN . MINER.