COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" - GENERAL INSTRUCTIONS Section 27111 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25266, 25257,and 25259 of Chapter 67, Divtsion 20£ health and Safety Code require tank owners to apply for ant IST operating permit, I One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE.' 2, -his form should be completed by either the PERMITAPPLICANT r the LCA AGENCY t� i F - - - G.iO l TANK INSPECTOR, R. . Please type or print clearly all requested information, 4. Use a.herd point writing instrument,you are making 3 copies. . Tank owners must submit a prat plan to the local agency showing the location of the USTs with respect to buildings and landmarks[2711 (a)( )CCR]. 6. Tank owners recast submit documentation shoring compliance with state financial responsibility'require- ments to the local agency for petroleum USTs[2711 (a)(111)CCR], TOP OF FCR MARK ONLY ONE ITE 1. Mark aro(X) in the box next.to the item that best describes the reason the form is being completed. 2.- In ica to the DBA or Facility name where the tank is installed. !a TANK DESCRIPTION - COMPLETE ALL ITE « IF UNKNOWN mSO SPECIFY A. Indicate owners tank I D#-if there is a tank number that Is used by the owner to identify the tank(ex: AE707S9). S. ' Indicate the name of the company that manufactured the tank(ex,ACME TANK FG), C. Indicate the year the tank was installed (ex. 1957), D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.), II. TAMC'CONTENT A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items R&C. 2. if not MOTOR VEHICLE FUEL,check the appropriate box in section A-arse mplete items`I D. E. 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.S,#, (Chemical Abstract Service number), if box 11s NOT checked in A. Ill. TANK CONSTRUCTION- MARK ONE ITEM ONLY IN BOX A, B, C & D 1. Check only one iters 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 applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided; 3, Indicate the LEAK 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 reclUr meats for the tank. I. INFORMATION ON TANK PERMANENTLY CLOSED. IN PLACE 1. ESTIMATED[SATE LAST USED-MONTHNEAR(January, 1985 or 01166) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). . WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED NCLCATEU [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county numbep the three digit jurisdiction number,the six digit fabilitynumber and-the six digit tarok number. The county and jurisdiction numbers are pCedeterim—InecFi6d can be obtained by calling the State Board(916)227-4303, The facility number must be the same as shq n. rrn "A". The tan umber may be assigned by the local agency,however,this number mast be numerical and cannot°bontain 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:FACILITY TO VERIFY THE ACLU- RACY OF TH INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE OILY" INFORMATION ECX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PLIC CCPV SHOULD BE RETAINED BY THE TANK N R.