COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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INSTRUCTIONS =C R COMPLETING FORM `B" GENERAL INSTRUCTIONS NS Section 2711 of Title 23, Division 3, Chapter'1 6, California Code of Regulations and sections 25236,25267, and 25269 of Chapter 6.7,Division 26, Health and Safe y Code require tank owners to apply for an DIST operating permit. 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE, . This form should be completed by either the PERMITAPPLICANTor the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. . Use a hard point writing instrument,you are making 3 copies. . Tank owners must submit a plot plan to the local agency showing the 14.0ation of the LISTS with respect to buildings and landmarks(2711 (a)(S)CCR], A: . bank owners must submit documentation showing compliance with state financial respft, ;bility require- ments e uir - ments to the local agency for petroleum LSTs(2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITE 1. Markanr X)in the box nextto the item that best describes the reason the form ; 2. Indicate the DBA or Facility name where the tank is installed. . TANK DESCRIPTION - COMPLETE ALL ITEMS ® IF UNKNOWN ffi SO PECIF`° A. Indicate owners tank 13 if there is a tank number that is used by the owner to idea, AB70769}a B. Indicate the name of the company that manufactured the tank(ex.ACME TANK-MFGY, C. Indicate the year the tank was installed(ex. 1967). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.), It. 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 complete items B&D. B. Check the appropriate box. 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.S,#. (Chemical Abstract Service number), if box 1 is NOT checked in Am Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & C 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. if OTHER, print in the space provided, €V. PIPING INFORMATION 1. Circle"A"if above ground circle"U"if underground, and circle both if applicable. 2. If UNKNOWN circle;or if OTHER,print in space provided. . Indicate the LEAD DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. 1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- MONTHNEAR(January, 1933 or 01/63) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT"MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED N I-CATEC (see section 2711 (a)(13) CCR] INSTRUCTION FCR THE LOCAL AGENCIES The state underground storage tank identification number i composed of the two digit county number,the three digit jurisdiction slumber,the-six digit�fadilit hip er and t "six`di it tank number. The county and jIuris idtidn numbers are predet fined and can be obtained by calling the State Board(916) 7-4303, `he facility number mustbe the same as sh n in form"A". The tank num � be assigned by the local agency,however,this number must be numerical and ca►i of contain an alphabet, f-,thejloca 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 FACILITY TO VERIFY THE ACCLI- RACY OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION CF THE "LOCAL, AGENCY USE ONLY" INFORMATION Bien THE LOCAL AGENCY SHOULD .RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK PY SHOULD BE RETAINED BY THE TA OWNER.