COMPLIANCE INFO_1997-2002 - 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 25266, 25267,and 25239 of Chapter 6.7, Division 20,Health and Safety Code require tank owners to apply for an UST operating permit. 1. One FOR "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHAOES, REMOV- ALS and/or any other TANK INFORMATION CHANGE, his farm should be completed by either the PERMIT APPLICANT"or the LOCAL AGENC`!UNDER- GROUND TANK INSPECTOR. . Please type or print clearly all requested info Mian. 4. Use a hard point writing instrument,you are making 3 copies. 5. Tank ownrs must submit a plot plan to the local agency showing the location of the UBTs with respect to buildings and landmarks[2711 (a)(6)CCR]. & Tank owners must submit documentation showing compliance with state financial responsibility require- ments to-the local agency for petroleum U Ts[2711 (a)(11) TP OF, FORM: MARK ONLY ONE ITEM y 1. Park a (X) in the box next to the item that best describes the reason the form is being,completed. 2. Indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION COMPLETE ALL ITE IF UNKNOWN�. d SPECIFY A. Indicate owners tank ID#-If there is a tank number that is used by the miner to identify,the tank(eke A 70769). 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). Indicate the tank capacity in gallons( x.25,000 or 10,000 etc,).` II. 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 complete items B. Check the appropriate box, C. , Cheek the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). D. Print the chemical nae of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 .1s NOT checked in A. Ill. TANK CONSTRUCTION ARIL ONE ITEM ONLY IN BOX A, B, C , D 1� Check only one item in TYPE OF SYSTEM,'ANIS MATERIAL, INTERIOR LINING and CORROSION' PROTECTION. 2 If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A"if above ground circle"U"if underground,and cirq7e both if applicable. . If UNKNOWN circle;or if OTHER, print in space provided. 3. Indicate this LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping: V. TANK LEAK DETECTION 1: Indicate the EAi " "TECTICN tem(s)used to comply with the.monito(ing requirements for the tanks VIe INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ,1 ESTIMATED DATE LAST USED- MONTHNEAR (January, 1966 or 01166)` Y 2. ESTIMATED ATED UANTI of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), m 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) CC INSTRUCTION FOR THE LOCAL.AGENCIE - e 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 and(916)` 7®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 Mate Board to assign the tank"number,please leave it blank. IT IS THE RESPON BILITY'OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE A CLI- RACY CF THE 'INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE ,LOCA)., AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK )6 SHOULD BE RETAINED BY THE TAN NER.