COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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JN8TOILICTIONS FOR COMPLETING FLIT "B" INE AL INSTRUCTIONS ' N SO on 2711 of Title 23, Division ion 3,Chapter 15, California Code of Regulations and sections 25236, 25237,and 25239 of Chapter 6.7, Division 20,health and Safety Code;require tank ou riers t6pplV for an UST operating permit. `l. Cine FORM"B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK'INFORMATION CHANGE.- 2'.' I A iGE..2•.= This form shouldbe completed by dither the PERMIT APPLICANT or,the LOCAL AGENCY UNDER- GROUND N E - GFCNO TANK INSPECTOR— , . Pledso typo or print clearly all requested information, 4. Use a Bard point writing instrument,you ara making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the UST-with respect to buildings and landmarks[2711 ( )(9)CCR], . Tank owners must submit documentation showing compliance with,stat financial respo sli ility require- ments to the local agency for petroleum U Ts[2711 (a)(1 )6C . `OF OF FCS K ONLY,ONE ITEM 1 a arfc, n.-( in the box next to the item that best-describes the reason the,form is bei M . 2. Indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION w COMPLETE ALL ITEMS m IF tf ECI `� A. "Indicate owners tank I -If there is a tank number that is used by the owner td oder:.::;; (ex. A 70759), S. Indicate the none of the company that manufactured the tank(ex.ACME TANK FO:. C. Indicate the year the tank was installed(ex 1957). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). Ila 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 Aand complete items B&D. E. Check the appropriate box. C. Check the type of MOTORVEHICLE FUEL(if box 1 is checked in ). D. Print the chemical name of the hazardous substance stored in the tank and the .A:S. .(Chemical Abstract Service number),if box 1 .is NOT checked in A. Ill. TANK CONSTRUCTION -MARK ONE ITEM ONLYIN BOX A, B, C 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. '2. If OTHER,pont in the space provided. Ill. 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. . 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 ATE LAST USED®MONTHNEAR(January, 1988 or 01183) . 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). . WAS TANK FILLED 1TH INERT ATE IAL? C "Y°es"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE E FOAM AS INDI- CATED (see section 2711 a (13)CCR] INSTRUCTION FOR THE LOCAL A E CIES 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 shown in form"A". The tank number may be assigned by the local agency,however,this•number must b6numerical 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 VERtFY THE AC - ACY OF THE INFORMATION,N, TIME LOCAL AGENCY IS RESPONSIBLE FOR THE COR L IO OF THE "LOCAL AGENCY USE ONLY„ INFORMATION BOX. ,THE LOCAL AGENCY SHOULD AIN THE:ORIGINAL AND YELLOW COPIES. TLIE PINKC SHOULD BE RETAIINED ° THE TAN NE .