COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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STRUCTIONS FOR COMPLETING FORM "B" -004EAAL INSTRUCTIONS; ` j, _ Section 2711 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25286,25287,and 25289 of Chapter 6.7,Division 20, Health and Safety Codes requirw4ank o td' br an UST operating permit. ` 1. One FORM"B"shall be completed for leach tank for,all PEiMITS,P EF)MiT CHANGES, REMOV „ AL'S and/or any other TANK INFORMATION CHANGE r, 2. This form should'be completed by either the PERMIT AP06CAor the�c�cAL Ad NQ UNDER- a.. GROUND'TANK INSPECTOR. r 3. Please - r type or prim clearly all requested information. .- 4. Use a hard point writing instrument,you are making 3 copies. " 5.- Tank owners must submit a plot plan to the local agency showing tw-cacatic of the USTs with respect to buildings and landmarks[2711 (a)(8)CCRj. 6. Tank owners must submit documentation showing compliance digits state to l nancial responsibility require- ments to the local agency for petroleum USTs 2711 . _. 9 Y Pe [ (a)('t'i`)CCiq:" TOP OF FORM: MARK ONLY ONE ITEM _. _ _ .7.. '1. =:,Mark an X in the box next-t the intern#11a .best describes the reason aeon ":.1s being completed. 2. Indicate the DBA or Facility name where the tank is installed. I TANK DESCRIPTION - COMPLETE ALL ITEMS ='iF'UNKNOWN - SO SPECIFY A, 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). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 0,000 etc.). 11. TANK CONTENTS A. 1 IF MOTOR VEHICLE FUEL,check box 1 and complete' ms B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate bd t to 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 ick A). D. Print the chemical name of the hazardous substance stoed in the tank and the G.A.S.#. (Chemical Abstract Service number),if box 1.is NOT checked in A ; Ill. TANK CONSTRUCTION -MARK ONE ITEM ONLY IN"SOX A. r✓ & D 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 1. Circle"A"if above ground circle"U"if underground,and circle both if appPcabie, _ 2. If UNKNOWN circle;or if OTHER;print in space provided. 3. Indicate the LEAK DETECTION systems)used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION _. 1. Indicate the LEAK DETECTION system(s)used to>sariply with the ,. , . _3, requirements for the tank VI. INFORMATION ON TANK PERMANENTLY CLOSED. IN JPLACE 1. ESTIMATED DATE LAST USED-MONTHIYEAR(January, 1 :Os!` ) ._ 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining inrlhe4ink(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL! Check"Yes"or"Nib": TANK OWNER OR AUTHORIZED REPRESENTATIVE-MUST ICr A1'l `DA"i TSE FQ ,pS,INDI- GATED [see section 2711 (a)(13) CCR] -- INSTRUCTION FOR THE LOCAL .AGENCIES '1 The state underground storage tank,.identficati_on number is composed of the two digit county number,the three digit jurisdiction number,the six digit facility number andthe six digit tank number. The county andjurisdicton numbers are predetermined and can be•obtained by calling the State,Board(916)227-4303. The faciliitynumbet 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 containan alphabet. If the local agencyprefers;the State Board to assign fl e;t io 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" INFORMATION BOX. THE LOCAL AGENCY SHOULD"RETAIN THE ORIGINAL AND YELLOW.COPIES. THE PINK,C SHOULD BE RETAiNED ,13 .=THE TANK NER.