|
�_
<br /> INSTRY� TIONS FOR COMPLETING FORM,"B"
<br /> ENERAL INSTR.UCT4ONS '
<br /> _ection 2711 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25286,25287,and 25289
<br /> ' of Chapter 6.7,Division 20,Health and Safe*Code requlr 1aink-owners to apply for an UST operating permit.
<br /> _1._- 4ne.T="0R`M"8"shall be completed for each tank for aiI NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> "` v ALS and/or any other TANK INFORMATION CHANGE
<br /> + 2: " This form should be completed by'either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- .
<br /> s.. __. " GROCiNUTANK INSPECTOR.
<br /> 3. ....:-PleaseAype or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies. , :
<br /> 6.__ Tamers must submit a plot plan to the local agency showiM this-16ation of the USTs with-respedt
<br /> } to b'bildings and landmarks j271 i (a)($)CCR].
<br /> - 6. Tank 6iwr s must submit documentation showing compliance with state financlat respo;vibility require-
<br /> ments tithe local agency for petroleum USTsJ271i-(a)(11}`CCR]:
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> :} ,Mark an(X) in the box nextto,the item that best describes the r` ate form is being ; t ter;.
<br /> -` L. Indicate the DBA or Facility name where the tank is installed.
<br /> l 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN -a 3 SPECIFY—
<br /> A. Indicate owners tank ID#-If there is a tank number that is used by#Wftftr to idetr, u .k
<br /> AB70789).
<br /> B: °Indicate the name of the company that manufactured the tank;(° .ACME TANK MF f
<br /> 0. Indicate the year the tank was installed(ex. 1987).
<br /> _ D. - Indicate the tank capacity in gallons(ex.25,000 or;'f6,1060:010.
<br /> II 'CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,checkbox i and complete items B:,&C.
<br /> = _2. If not MOTOR VEHICLE FUEL,checklhe sppropriate box in secti6n.A andcompleteitems B&D.
<br /> B. Check the appropriate box.
<br /> :.A
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in,k _
<br /> - D. Print the chemical name of the hazardous substance stored in the tank and the C.A.SM. (Chemical
<br /> Abstract Service number),if box lis NOT checked h"A.:
<br /> 111. `TAAK CONSTRUCTION -MARK C?NE` ITEM ONLY IN SOX A,.:B, $� 'D
<br />` 1 ,.Check only one Clem in TYPE OP SYSTEMJANK MATERIAL,.I h LINING and CORROSION'
<br /> PROTECTION.
<br /> 2. If OTHER,print in the spam provided. . m..
<br /> 1fit �". PJPING INFORMATION -
<br /> f. Circle"A" if above 4round circle"U".if underground,and circle both if applicable. u
<br /> _-2. If_UNKNOWN circle;or if OTHER,print in space proidde
<br /> 3. InlJicate the LEAK DETECTION s £tem s used to cont ,
<br /> ys ( ) pIy with to monitoring requirement for the,piptrig.
<br /> V _` TANK .LEAK-, CTION
<br /> 1. > Indicate the TEAK DIM01 ON s m(s)used to comply with the.monitoring*requirements for the tank w--=
<br /> w. Y.-- �_JNFaORMATION ON TANK PERMAN-ENTLY CLOSED W44ACE,
<br /> 1._ 'ESTIMATED DATE LAST USED-MONTHNEAR(January, 1988 or 01,188)
<br /> 2., ESTIMATED QUANTITY of HAZARDOUS'SUBSTANCE remaining in the tank(in Gallons).
<br /> 3:, '-WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR,AUTHORIZED REPRESENTATIVE MUST SIGN A D,DATt-THE FORM AS lkbl-
<br /> CATED "[see-section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR I THE LOCAL AGENCIES a
<br /> The state under4r6und storage tli�@tttificati>p.ntmber ice*t�omposed of the two4glt county nurnber,the three digit
<br /> jurisdiction number the six digit facility number and the six-digit.tank number. The county and Jurisdiction numbers'
<br /> f predeterMiWd and can be obtained by calling the State Board(916)227=4303. The facility number must be the samoas
<br /> 4 �
<br /> shown'h ollm A' 'V tank number may be assigned by the local agency,however,this number must bih6merical aria
<br /> cannot cohaaiin an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> tT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY'-TO VERIFY THE ACCW,. - ,
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> ""LOCAL"AGENCY U8E ONII" INFORMATION BOX. THI=,`J` GENCY SHOULD RETAIN THE>QRIGINAL .AND
<br /> `YELL IES. '!` 1} ,C SHOULD BE.,,All N . SHE TANK INER.
<br /> s w_
<br />
|