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INSTRUCTIONS FOR C OI`AiFTI I i F'OFM "B"
<br /> GENERAL INSTRUCTIONS
<br /> IONS
<br /> Section 3711 of Title 33, Division 3, Cha r 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 8.7, Division 23, Health,and Set, . C=ode require tank owners to apply for an LIST operating permit,
<br /> 1. One FORM "B"shall be far each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION HANGS.
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCALAGENCY UIl w
<br /> :. 3. Please type or P.rl"?t clearly a0l c .'j.,€r...aesrs{' (I'tff7rr:'€rxtt'?n.
<br /> Use a,hard point writing instr;rneat,you are making 3 copies,
<br /> g, Tank owners nnust submit a plot plan to the local agency showing the location of the USTs with respect
<br /> to buildings and landmarks'271 t (a)(8) CCR],
<br /> 3. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum US T s(2711 (a)(11) S Ft),
<br /> TCT OF FORM., MARK ONLY ONE ITEM
<br /> 1, dark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> , Indicate the DBA or Facility name where the tank is installed.
<br /> I. TANK DESCRIPTION - COMPLETE ALL. ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID _ If there is a tank number that is used by the owner to identify the tank ex.
<br /> AB7Ct7B ).
<br /> B. Indicate the name of the company that rr,amufa ctured the tank(ex. ACME TANK FFG),
<br /> Ip, Indicate the year the tank was installed Iex, 1987).
<br /> D� Indicate the tank capacity in gallons ex, 35.030 or 10,300 etc.).
<br /> If. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C.
<br /> B. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items S&B.
<br /> B. Check the appropriate box.
<br /> S, Check the type of MOTOR VEHICLE FUEL(if box 1 'is checked in A),
<br /> 1, Print time chemical name of the hazardous substance stored in the tank and the C,A.S.#,, (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOX A, B, C & I
<br /> 1. Check only one iters in TYPE OF SYSTEM,TANK,MATERIAL, INTERIOR LI If and CORROSION
<br /> PROTECTION,
<br /> . If OTHER, print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> _
<br /> 1, Circle"A" if above ground circle "U" if underground, and circle both it applicable,
<br /> 3. If UNKNOWN circle; or if OTHER, print in space provided.
<br /> . Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED BATE LAST"USED- f? ONTH11"FAR (January, 1988 or 01/88)
<br /> , ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Sees"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE TGIF FORM M AS II' I I-
<br /> -C:ATFt [see section 2711 (a)( ) SIT
<br /> INSTRUCTION FOR THE F LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county number, the three digit
<br /> jurisdiction number,the six digit facility number and the six'digit tank number. The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(913)227-4303. The facility number must be the same as
<br /> shown in form "A", The tank number may be assigned by the Ideal agency,however,this number must be numerical and
<br /> cannot contain an alphabet, If the local agency p+refers the State Board to assign the tank number, please leave it blank,
<br /> IT IS THE RESPONSIBILITY OF TE-trE' LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF T HE INFORMATION, THE LOCAL_ AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIME
<br /> "LOCAL AGENC=Y USE ONLY" INFORMATION BO . THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. TETE PINK COPY SHOULD BE RETAINED BY THE TANK 'OWNER.
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