COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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INSTRUCTIONS FOR CCM L IRNG FORM "B GENERAL. INSTRUCTIONS Section 27,11 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25256,25237, and 25259 of Chapter 6.7,Division 20, Health and Safety Code require tank owners to apply for ars UST operating permit., 1. OneFORMFACE,shall be completed for each tank for all NEW PERMITS, PERMIT"CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed y either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- - OROU TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are,snaking 3 copies. 5, Tank owners must submit a plot plexi to the local agency showing the location of the USTs with respect to buildings and landmarks(2711 (a)( )CCR]. . Tank owners must submit documentation showing compliance with state financial resp, ,L=ility require- ments to the local agency for petroleum USTs[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITE 1. Mark an(X)in the box next.to the item that best describes the reason the form is be, _. 2. Indicate=the DBA or Facility name where the tank is installed, la TANK DESCRIPTION - COMPLETE ALL ITEMS IF UNKNOWN, - SO SPECIF';' A. Indicate owners tank IC#-If thea is a tank number that is used by the owner to ides° ' r _ :3x A7079)._ B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG:): 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® TANK` CONTENTS A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items 8&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and comP'ete iterns B&b. S. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). C. 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 A. Ill., TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C 1. Check only one item in TYPE OSYSTEM,TAN MATERIAL,RI , INTERIOR LIMING axed CORROSION PROTECTION. x, r . If OTHER, print in the space provided: IV. PIPING INFORMATION t 1. Circle"A"if above ground circle"U"if underground,and circle both if applicable. 2. If UNKNOWN circles or if OTHER, print in space provided. . 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 themonitoringrequirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED-MONTHNEAR(January, 1956 or 01166) 2. ESTIMATED QUANTITY of HAZARDOUS Cf STANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERTMATERIAL? Check"Yes"or"No TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR} INSTRUCTION FOR THE LOCAL.AGENCIES The state underground storage tan .,identification number i composed of the two digit county number,the three digit jurisdiction number,the six digit facility number and the six digit tank number, The county and jurisdiction numbers are predetermined and can be obtained by calling the Mate Board(916);; 7-4303. The facility number must be the same as showrrin f "A". The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please]eve 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 "LO=CAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIG!NAL AND YELLOW COPIES, THE PINK. COPY SHOULD L BE RETAINED -BY.THE TANKS NER.