COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS FOR COMPLETING FORM "B^ GENERAL INSTRUCTIONS- Section |NSTRUCT|[)N8Secbon2711ofTiUa23. Division3. Chapter1EiCpddomiaCodacfRegulatiomoamdsections 2528G. 25287. and25289 ` ofChapter S7. Division 2O. Health andSatatj Code require tank owners toapply for anLIST operating permit, 1. One FORM "B''mhaUbecom letecl for eachtank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. om |etedbyeither1hePEB7N|TAPPUDANTo/thoLOCALAGENCYUNDER- GROUNDTANK |NSPEOTOR. 3. Please type orprint clearly all requested information. 4. Use ahard point writing instrument, you are making 3copies. 5` Tank owners must submit aplot plan knthe local agency showing the location ofthe USTowith respect bobuildings and landmarks[2711 (a)(8) CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments tothe |ooa| agenuyforpetro|eumUSTo[2711 (a)(11) 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 orFacility name where the tank iainstalled. 1. TANK DESCRIPTION - COK8PLETE ALL |TEMG - |F UNKNOWN - 8O SPECIFY A. indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7078Q). B. Indicate the name of the company that manufactured the tank (ex, ACME TANK MFG). C. Indicate the year the tank was installed (*x. 1987). D� Indicate the tank capacity ingallons (ex. 25.DODor10.D0Oeto.). ||. TANK CONTENTS A. 1. !FMOTOR VEHICLE FUEL, check box 1and 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. C� Check the type ofMOTOR VEHICLE FUEL(if box 1 iochecked inA)� D. Print the chemical name ofthe hazardous substance stored inthe tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1iaNOT checked inA. |||. 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 inthe space provided, |V. PIPING INFORMATION 1. Circle"A" ifabove ground circle"U" ifunderground, and circle both itapplicable, 2. |fUNKNOWN circle; o,ifOTHER, 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 (January, 18B8orO108) 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 ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AB INDI- CATED [see section 2711 (a)(13) CCRI INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank idtih \i b is composed ofth 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. ��