COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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|0STBUCT|ONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 ofTitle 23, Division 3, Chapter 1G. California Code ofRegulations and sections 2G288. 25287` and 252BQ niChapter 67^ 20. Health and Safety Code require tank owners toapply for anUST operating permit. 1Ons FC)RY, '`B"shallbe completed f all� NEW PERMITS, PERMIT CHANGES, REMDV' �yand/Or any otherTANK 1NFDRKAAT|ONCHANGE. 2 -ie PERMIT APPLICANT orthe LOCAL A{3ENCYUNOER' GBOUNDTANK INSPECTOR. 3. Please type orprint clearly all requested information. 4. Use ahard point writing instrument,you are making 3copies. 5. Tank owners must submit a plotplan tothe local agency showing the location ofthe USTowith respect to buildings d landmarks (a)(8)CCR]. S, Tank owners must submit documentation showing compliance with state financial responsibility require- mentsto#he|ooa|agencyforpetno|eumUGTo[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an(X)inthe box next tothe item that best desohbeothe reason the form iobeing completed. 2. Indicate the DBA orFacility name where the tank isinstalled. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - S[) SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78g). B. Indicate the name ofthe company that manufactured the tank(ex.ACME TANK K8FG). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity ingallons(ex.25`800or10.000 etc.). |i. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL,check box 1and complete|benooB&C. 2. |fnot MOTOR VEHICLE FUEL,check the appropriate box insection Aand complete items B&D. B. Check the appropriatebox. C. Check the type ofMOTOR VEHICLE FUEL(if box 1imchecked inA). D. Print the chemical name cfthe hazardous substance stored inthe tank and the C.A.S.#. (Chemical Abstract Service numbar). ifbox 1ieNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY |NBOX A. B, C & O l. Check only one item inTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. ' 2. IfOTHER,print inthe space provided. |V. PIPING INFORMATION 1. Circle^A^ifabove ground circle"U"Kunderground,and circle both if applicable. 2. |fUNKNOWN circle;orifOTHER, print inspace provided. 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAKDETECTIONwystem(s)used toconiply with the monitoring requirements for the tank. V|. INFORMATION ONTANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED' K8ONTHNEAR(January, 1S88orD1/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). O. WAS TANK FILLED WITH INERT MATERIAL? Cheok°Yea^ur"No". TANK OWNER {}R AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM ASINDI- CATED [see section 2711 Aa>(13) CCR) INSTRUCTION FOR THE LOCAL AGENCIES The state underground ato tank identification b is dofthe 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 numedcal 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 TO VERIFY 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 CW SHOULD BE RETAINED BYTHE TAN NER.