COMPLIANCE INFO_2000-2003 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit, -,tea 1. One FORM "B"shall be completed for each tank 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: 3. Please type or print 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 US T s with respect to buildings and landmarks[2711 (a)(8)CCR]. - 6. Tank owrFers must submit documentation showing compliance with statd financial respc-:.sil ilily require- ments to the local agency for petroleum USTs[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 be 2. Idicate the DBA or Facility name where the tank is installed I. TANK DESCRIPTION - COMPLETE ALL ITEMS = IF UNKNOWN - SO SPECiFrl A. Indicate owners tank ID#- If there is a tank number that is used by the owner to ides ex. AB70789). B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG,. C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). IL TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and compic le iterns B&D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked iq A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 .is NOT checked in A. Ill. 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 a�iJ CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION 1.- Circle"A"if above ground circle"U"if underground, and circle both if applicable. 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 f `"Indicate the LEAK DETECTION syster s(s)used to d6ply with the Monitoring requirembnts for the tank. V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED-MONTHNEAR(January, 1988 or G1488) 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 FORM AS INDI- CATED [see section 2711 (a)(13) CCA] INSTRUCTION FOR THE LOCAL Ara. qQE$_..-_ 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 obtaiNd by.calling the State Board(916)227-4303. The facility number must be the same as shown in &!-` "A"'. The tank num -ii 4 be assigned by the local agency,however,this number must be numerical and cannot c6rrt441n^IpAabIf the local agency prefers the State Board to assign the tank number, please leave it blank. r. IT IS THE R PONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- 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 CCIPY SHOULD BE RETAINED BY THE TANI CNER.