COMPLIANCE INFO_1998-2002 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING R3RK8 "B" GENERAL INSTRUCTIONS Section 2711o/Title 23. Division 3. Chapter 1H. California Code cfRegulations and sections 2528G. 25287, and 2528Q ofChapter SJ. Division 2O. Health and Safety Code require tank owmontoapply for anLIST operating permit. 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALSand/orany other TANK INFORMATION CHANGE, 2. This form should b completed byeither the PERMIT APPLICANT orthe LOCAL AGENCY UNDER- GROUND TANK |NSPECTOR. 3. Please type orprint clearly all requested information. 4. Use ohard point writing instrument,you are making 3copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect tobuildings and landmarks[2711 (a)(8)CCR]. O. Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs(2711 (a)(111) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describes the reason the form is 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. AB7U783). B. Indicate the name ufthe company that manufactured the tank(ax.ACME TANK MFG). C. Indicate the year the tank was installed (nx. 1Q87). D. Indicate the tank capacity ingallons (ex. 25.000or10.000p1o.). ||. TANK CONTENTS A� 1. {FMOTOR 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 bnx. C. Check the type cdMOTOR VEHICLE FUEL(if box 1 iochecked inA). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1 isNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A' B` C & D 1. Check only one item inTYPE C}FSYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |(OTHER, print inthe space provided. |V. PIPING INFORMATION 1. Circle"A"if above ground circle "U" if underground, and circle both if applicable. 2. ifUNKNOWN circle; orJOTHER, print inspace 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 requirements for the tank. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED ' MONTH/YEAR nuury. 1S88nrO1/88) 2. ESTIMATED QUANTITY n/HAZARDOUS SUBSTANCE remaining inthe tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check''Yea"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 undergroundoto ntankidendMcaUonnumber)000mpoaednfthetwmdigitcountynumber the three digit jurisdiction ''~'''~~''the—''—=-facility— number and the —'digit— ---n �l - count� ' and must same as iction numbers are predetermined and can beobt�nedbyca8/ngthe Gt�eBoard(31S)227~43O3. The facility numbermu shown inform''A" The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain onalphabet. 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 ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USEONLY"' INF DN B0%. THE LOCAL AGENCY GH D RETAIN THE ORIGINAL AND YELLOW COPIES. THE Pit W��S��JLD BE RETAINED BY THE TANK ��