COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711ofTitle 23, Division 3` Chapter 18. California Code ofRegulations and sections 252B8` 25287. and 2528A of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit, 1. One FORM ^B''shall beoom !eiedfor each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS'and/orany other TANK INFORMATION CHANGE. 2. This form should becompleted byeitherthePERK8iTAPPL|CANTor1hmUOCALAGENCYUNOER- GROUNDTANK INSPECTOR. 3. Please type orprint clearly all requested information, 4. Use ahard point writing instrument,you are making 3copies. 6. Taok 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]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- ments Vothe|uca|agency for petroleum U8TaC2711 (a)(11) CCR]. TDP OF FORM: MARK ONLY ONE ITEM - 1. Mark an (X) in the box next to the item that best de$cribes the reason the form is being completed. 2. Indicate the DBA orFacility name where the tank iminstalled. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - 8O SPECIFY A. Indicate owners tank |D#- |fthere is atank number that|sused bythe owner toidmnbfvthe tank(ex. � ' AB7U789 B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG). C. Indicate the year the tank was installed (em. 1Q87). D. Indicate the tank capacity ingallons (ex. 25.000or10.000etu)� U. 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 insection Aand complete items B&D. B. Check the appropriate bon. C. Check the type cfMOTOR VEHICLE FUEL(if box 1 iochecked inA). D. Pirint the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service numbur). ifbox 1 iaNOT checked|nA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A. B. C & D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION � PROTECTION, 2. |fOTHER, print|nthe space pnovided� |V' PIPING INFORMATION — 1. Circle"A" ifabove ground circle"U" ifunderground, and circle ' bothif applicable. – 2. IfUNKNOWN circle; orifOTHER, 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 (Jonuary. 1988nr01/88) 2. ESTIMATED QUANTITY u|HAZARDOUS SUBSTANCE remaining |nthe 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 [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 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 State Board(916)227-4303. The facility number 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 contain 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 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 COPY SHOULD BE RETAINED BY THE TANK OWNER.