COMPLIANCE INFO_1998-2007 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711ofTitle 23.Division 3`Chapter 1S.California Code cfRegulations and sections 25286.25287.and 2528Q ofChapter 67.Division 2O.Health and Safety Coden»quinetanhmwnemtoapp|yforanUSTopomhngpenniL 1One FORM "B''shall becompleted fore htankforaUNEVVPERM|TS.PERM|TCHANGES.REK8OV' ALS and/or any otherTANK INFORMATION CHANGE. 2. This form should becompleted byeitherthePERM|TAPPL|CANTortheLDCALAGENCYUNDER' GRDUNDTANK|NSPECTDR. 3. Please type orprint clearly all requested information. 4. Use a hard 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 8nbuildings and landmarks [2711 (a)(8) CCR]. S. Tank owners must submit documentation showing compliance with state financial responsibility require- mentsto1ha|oou|agencyfo/petnm!eumUSTo[2711 (a)(11)CCR]. TOP OFFORM: MARK ONLY ONE ITEM 1. Mark an(X)inthe box next 0mthe 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 ITEMG- 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. AB7O78Q). B. Indicate the name of the company that manufactured the tank (ax. ACME TANK MFG). C. Indicate the year the tank was installed (ex.1Q87). D. Indicate the tank capacity ingallons (ex.25.0UOor1O.00Ue1o]. 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 in section A and complete items B & D. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL (if box 1 imchecked 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 ioNOT checked in& |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B. C & D 1Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. }fOTHER, print inthe space provided. N. PIPING INFORMATION 1� Circle "A" ifabove ground circle 1J"if underground, and circleboth ifapplicable. 2. If UNKNOWN circle; or if OTHER` print in space 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 system(s)used to comply with the monitoring requirements for the tank. Vi INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED -MONTH/YEAR 1/88 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 OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORMAS 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 OFTHE 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" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED 8YTHE TANK OWNER.