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I TRI TP S FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> 8eptlon'2711 of Title 23,Division 3,Chapter 16,CaliforniaCode of Regulations and sections 25266,25237,and 25259
<br /> of Chapter 61,'Divislon 20, Health and Safety Code;require tAnkawrjem,toapply f r an LIST operating permit.
<br /> 1. 'One,FORM"B"shall be completed for each tank for all,NE,W
<br /> °R#TMITS;PERMIT HA S,
<br /> REMOV-
<br /> Land/Or any other TANK INFORMATION HANGS
<br /> c. hreeMI11
<br /> LICANT,of the LOCAL AGENCY UNDER
<br /> R II
<br /> TANK INSPECTOR.
<br /> 3, Please typo or print clearly all requested information,,'
<br /> a Use s hard point writing instrument,yoara making 3 ;0p&,. .
<br /> 5. Tank owners must submit plot plan to the local agency showing file location of the USTs with reappet
<br /> to buildings and landmarks(2711 ( )(6)OCR],
<br /> 6. T nk owners roast submit ddo rn tstiort showing cornplianco,withatate,financial responsibility require-'
<br /> menti to the Ideal agency,for petroleum USTS 1271 f(a)(11) b
<br /> TOP ONLY ONE ITEM
<br /> t. ark, )In the next to the item that best describesthe,reason,theform is being completed:
<br /> 2.. Indicate1le DBA orFaciflik name er the tahkis Installed.
<br /> L TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN, $0 SPECIFY
<br /> A. Indicate o.ners tank I -If there is a tank numberthat is used by the,owner to identify a tank( ,
<br /> 737 )_
<br /> S. Indl at the name of the company that manufactured the tank(ex.' T )s
<br /> C. ;Indicate year the tank was installed(6 7)a
<br /> Indicate the tank capacity in gallons(ex.215,00or 1` , et6.); ,
<br /> I. TANK
<br /> A. 1; IF tTfR VEHICLE FUEL,check box 1 and tttplete items C.
<br /> I not ICL L, arodt In ° m d rr�plete iters
<br /> heckheckthe,appropriate boo
<br /> Ci Check'thietype of MOTORVEHICLE FUEL(if box 1 i dh ked,l A).
<br /> D. Print the chemical name of the hazardous substance,stored,ih the. n and the 4S,#: (Chemical
<br /> Abstract Service number),if box 1 Js NOTrhecked in A.
<br /> fila T I ' UTI IC ONE ITEM ONLYIN BOX,A, & D
<br /> 14 Check only oneitem,ln TYPE OF SYSTEM,TANK,mATeRIAL,I I LINING and CORROSION
<br /> F "T STI .
<br /> m If C)THER,,print in the space provided.
<br /> i/R
<br /> PIPING 'INFORMATION
<br /> 1, circle�` �f abl e grdtand it le"U"If ndergr und, le bdt 'i ll ble>
<br /> I IK i le or If T # g print In space provided"
<br /> 3. �Indl t the L Tl system(s)�em(s)used to
<br /> monitoring requirement for piptr
<br /> V. TANK LEAK, DETECTION
<br /> 1. Imo€ t LEAK system(s)p .,'
<br /> y ,. ,.: o g r lair r for rtk ; '
<br /> I LA it
<br /> 10N'ON TANK PERMANENTLY- CLOS,"JE
<br /> 1. STi,A� T ST - T: ( nL ry,1 011 88)
<br /> n
<br /> 5TI_' "T t TI o t3 re t ~is€ tank n Ildrrs};
<br /> 3. WASTANJkFILLED WITH INERT AT I,I L?
<br /> T U I `TI t 1" ) f T I I
<br /> ITR
<br /> tTl A AGENCIES
<br /> The state . r rou store e nk dentl tion ncamber iscomposed of the,;. 'digit pa my r��€m er8 the e digit,
<br /> jurisdiction Tzu b , `i digit f ili num r e , e six ` i It r� er. TIi county and oris l ti n numbers' are
<br /> predetermined can,be, a obtained calling e State (9,1,6) 3a r, f -iii number must
<br /> shown f �, � number ' y s€gr ' b I 'riM g r► hb ver,, f `rr Umber st b nu ersd6I and
<br /> cannot ire>an alphabet. .Ifthe I agency,prefers the roto es ign t tink number,please les e f t blank,
<br /> lT IS `Thi R I i II�tT F THS L L AGENCY I T Il (S,TI I ILI fVERIFY �f A 1 -
<br /> RACY THE INFORMATION.
<br /> THE LOCAL AGENCY,I RESP Sl T 1 °' R l l T
<br /> "LOCAL AGENCY LI 1LY- INFORMATION BOX. THE FOCAL AGENCY OULD RETAIN THE:' RIGI AL A;
<br /> YELLOWCOP115S.- Ti Ill 1 L3L, E R 1 Y"THEto . ..
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