COMPLIANCE INFO_2000-2005 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B^ GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division D. Chapter 1S' California Code ofRegulations and sections 2528G.25287. and 2528Q of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. 1. One FORM "B" shall bocompleted freaoh1ankforaUNEWPERKA|TS. PERM|TCHANGEG. REK8OV' ALS and/or any otherTANK INFORMATION CHANGE. 2. This form should bo completedbyoi1her1hePERM|TAppL|CANTor1heLOCALAGENCYUNDER- GROUNDTANK |NSPEOTDR. 3. Please type nrprint clearly all requested information. 4. Use ahard 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 (a)(8)CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs[2711 (a)(1 1)CCR]. ` TOP OF R3RK8: MARK ONLY ONE |TEV. � 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DRAorFacility name where the tank ioinstalled. ' |. 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. AB7878g). B. Indicate the name ofthe company that manufactured the tank(as. ACME TANK MFG). .— C. Indicate the year the tank was installed (ax. 1S87). D. Indicate the tank capaoityingallons(ex.25.00Oor10'DU0et .). _ U. TANK CONTENTS ' A. 1. |F MOTOR VEHICLE FUEL, check box 1and complete items B& C. . 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section Aand complete items B&D. B. Check the appropriatebox C. Check the type nfMOTOR VEHICLE FUEL(if box 1 iechecked 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 ieNOT checked inA. Ui TANK CONSTRUCTION ' MARK []WE ITEM ONLY IN BOX A, B. C & [] / . 1. Check only one item inTYPE CF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. -2. IfOTHER, print inthe space provided. IV( PIPING INFORMATION - ' - . 1. Circle-"X if above ground circle"U" if underground,and circle-b6th if applicable. , . 2. hUNKNOWN circle; orifOTHER, print|nspace provided. .` . 3. Indicate the Lr=AK DETECTION system(s) used to comply with the monitoring requirement for the pipin I g. - V. TANK LEAK DETECTION ---E 1. Indicate ��haLE� DETECT|DNayabam�)usedto�omp��yw�hthomonho ' nequiremen'=-tsfor thetonk -^ — VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . . 1ESTIMATED DATE LAST USED- K4ONTH/YEAR (January, 1988or8nB8 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).. '- 8. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (o)(13) CCR] INSTRUCTION- FOR THE LOCAL AGENCIES The state underground sto tank idnbficatibe is composedofthe two digit b 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 shown inform"A". The tank number m ' this number must benumerical and ` cannot contain analphabet. |fthe local agency prefers the State Board bu assign the tank number, please leave bblank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY CU' ' RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION [)FTHE � "LOCAL USE ONLY" MAT{OMBDX. THE LOCAL AGENCY SHOULD RETAIN THE OR|GINAL'ANB AND- YELLOW �O�D�;. THE PINK SHOULD BE RETAINED BY THE TAN ��. '* ' ��' �� ,`^^°