COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

Home Browse Search

TRUCTIONS FOR COMPLETING FORM "R" INSTR TIONS *901AL ;rtt 711 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25286,25287,and 25289 Ohapter 6.7,Division 20,Health and Safety Code require tank owners to apply for an UST operating permit. —1 "Ori`A FQRM'B"shall be completed for each tank far;all N 1 PERIJITS,"PERMIT CHANGES, REMOV- ` ''-AL`S ndkir any other TANK INFO)RMATION CH., E 2. This"form-should be completed by either the PER tT A�PUCAi�tT or the LOCAL,AGENCY UNDER- d._.._.. --'-GROC ND'TANK INSPECTOR. r. ._._ ._._Pleam.ype or print clearly all requested information u .. . - �4. Use a hard point writing instrument,you are making,3 ee., 5. __..Tank owners-must submit a plot plan to the local agency showing-the location of the USTs wim,respect to buildings and landmarks[2711 (a)(8)CCR]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- - -.. ments to the local agency for petroleum USTs[2711 (a)(11) CCRj __TOP OF FORM: MARK ONLY ONE ITEM f. Mark an (X) in the box next to the item that best describes the reason the form is being completed. V 2 Indicate the DBA or Facility where",tank is installed. _ , 1 ' TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY - - •-'A:m_ Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex. AB70789). - - B 'indicate the name of the company that manufactured the tank(ex.ACME TANK MFG). t" C. Indicate the year the tank was installed(ex. 19870), ; D.- Indicate the tank capacity in gallons(ex.25,000 or10,000 etc:).. _. ,.If. , "'-'T °r✓ONTENTS - "A.'"" 1." IF MOTOR VEHICLE FUEL,check box 1 and complete lterns B&C. 2. IfnotMOTOR VEHICLE FUEL,check the appropriate bOx woon A and complete items 8&D. B. Check the appropriate box. - C. Check the type of MOTOR VEHICLE FUEL(if box 1 is p e&ed ;A). _.D. Print the chemical name of the hazardous substance stored in -tank and tl t.A.S.#. (Chemical Abstract Service number),if box i is NOT checked Ih A III. TANK CONSTRUCTION- MARK ONE ITEM ONLY IN ok A,i. B; G 'b 1 . ,.,Cheek only one item in TYPE OF SYSTEM,TANK-MATERIAL;INTtllbk INING'and`CORROSION`:_ PROTECTION. . , 2 If OTHER, print in the space provided _ w IV.-- PIPING INFORMATION : - 1. Circle"A"if aboveground circle"U'if underground,and circle both if applipable. -2. If UNKNOWN circle;or if OTHER,print in space provided. 3. Indicate the LEAK DETECTION system(s)used tomXi1y with the monitoring requirement for the piing. _ V TANK'LEAK DETECTION ... I.- Indicate the LEAK'DETECTION system(s)usedto comply with the monitoring requirements for the tank.` '. _VI. INFORMATION ON TANK PERMANENTLY CLOSED.IISI.f?LAM. x .; t. ESTIMATED DATE LAST USED- MONTHI (J" y, 19Cl88)_ 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in-the tank(in Gallons). '-T - 3.- WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"ear"No TANK OWNER OR AUTHORIZED REPRESENTATIVE I ST SIGN AND`INATE THE FORM AS INCA- i CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOICAL AGENCII=S - - -.• ` The state underground storage tank identification number is composed of the tw6ic ,66unty number;the three digit jurisdiction number,the six dig&&.* y?Wmber and the six-digit tank number. Th county and jurisdiction numbers are predetermined and can be obtained by calling the State 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 F, y 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 ,FACILfFY-TO VERIFY THE Accu.. , RACY OF THE INFORMATION. TAE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE LOCAL AGENCY USEONLY" INFO'RMATION15OX. THLw'LOCAL AGENCY SHOULD"RETAIN THE'-ORIGINAL-AND YELLOW COPIES. THE PINK_ SHOULD s I l? BY THE TAN NSR ',