COMPLIANCE INFO_1998-2009 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711ofTitle 23.Division 3,Chapter 1G.California Code ofRegulations and sections 2528S.25287.and 252OS 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 becompleted fore h tank for allNEW PERMITS, PERMIT CHANGES, REMOV- ALS und/oran other TANK INFORMATION CHANGE. 2. This form should be completedbyeithe,thaPERM|TApPL|CANTortheLOCALAGENCYUNOER' GRDUNDTANK|NSPECTOR. 3. Please type orprint clearly all requested information. 4. Use ahard point writing instrument, you are making 3 copies. ' 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)<]CR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments TOP OF FORM: MARK ONLY ONE ITEM 1. Mark anOQinthe box next to the item that best describes the reason the form iabeing completed. 2. Indicate the DBA or Facility name where the tank is installed. TANK DESCRIPTION - COMPLETE ALL ITEMS -|F UNKNOWN '8D SPECIFY A. Indicate owners tank |D#'If there isetank number that is used by the owner to identify the tank /ex. B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). C. Indicate the year the tank was installed (*x.1Q87). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). U. TANK CONTENTS A. 1.|FMOTOR VEHICLE FUEL, check box 1and complete items B&C. 2. |fnot MOTOR VEHICLE FUEL, check the appropriate box insection Aand complete items B&O. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL (if box 1 iachecked inA). D. Print the chemical name of the hazardous substance stored in the 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 inTYPE OFSYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print inthe space provided. K( PIPING INFORMATION 1. Circle "A" ifabove ground circle "U"ifunderground, and circle both ifapplicable. 2. |fUNKNOWN circle; orif OTHER, print inspace provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION Indicate the LEAK DETECTION mystem(s)used to comply with the monitoring requirements for the tank. Vi INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED 'MONTHy/EAR ry,1QB8orOn88 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check ^Yeo^or^No". TANK OWNER ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED 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 TOVERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFQLMATION BOX. THE LOCAL AGENCY SHOLI.LD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK C{��>��QHDULO BE RETAINED BYTHE TANK ��W�ER. IW —'^