COMPLIANCE INFO_1989-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Titin 23, Division , Chapter 16, California Cade of Regulations and sections 2620; 25237, and 26239 of Chapter 0.7, Division 20, Health and Safety Coe require tank canners to apply for an LIST operating permit. 1. One FORM £FBS shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES,REMOV- ALS aha/or any other TANK INFORMATION CHANGE, 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND NDER-aPCCND TANK INSPECTOR, 3. Please type or print clearly all requested information, 4, Use a hard point writing instrument, you ars: making 3 copies. 0. Tank owners must submit a plat plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(3) CCF]. 6. Tank owners must soot documentation shoeing compliance with state financial responsibility require- ments enuire-ments to the local agency for petroleum USTs (2711 (a)(11) CCR], TCT OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to to item that best describes the reason the form is being completed. 2. Indicate the IDEA or Facility name wore the tank is installed. 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - 1F UNKNOW - SCS SPECIFY A. Indicate owners tarok iC It - If there is a tank number that is used by the owner to identify the tank (ex. AS7 0760). S. indicate the name of the company that manufactured the tank (ex. ACME TANK MFG), C. Indicate the year the tank was installed (ex. 1987), Indicate the tank opacity in gallons (ex. 26,660 or 10,000 etc.). Ii, TAMC CONTENTS A. 1. IF MOTOR i VEHICLE FUEL, check box 1 and complete items B & C. , If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete neons 3 & D, S. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in 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. Ili. TANK CONSTRUCTION - MAFIA ONE ITEM ONLY IN BOX A, E, C & C 1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION N PROTECTION. 2: if OTHER, print in the space prodded, IV. PIPING INFORMATION 1. Circle "A" if above ground circle "Ll" if underground, and circle bath if applicable. 2. 1f UNKNOWN circle; or if OTHER, print in space provided. . 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. 1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED m MONTHJYEAR (January, 1033 or 01 /88) . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining ire 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 INCA- CATEi (see section 2711 (a)(13) CCF] INSTRUCTION FOR THE. LOCAL AGENCIES The state underground storage tank identifications number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tarok number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-433. The facility number must be the same as shown in foam "A". The tank number may be assigned by the local agency, -however, this number must be numerical and cannot contain are alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE HESPONSISILITY'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 "L KCAL 'AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND. YELLOW COPIES, THE PINK C Y SHOULD BE RETAINED ED EY THE TANKS NER