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INSTRUCTIONS FOR C MP TING FORA "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25256, 25237, and 25259
<br /> of Chapter 6.7, Division 20, Health and SafstV Code require tank owners to apply for an LIST operating permit.
<br /> 1. One FORD "B" shall be ccrnipd ted for each tank far all NEW PERMITS, PERMIT" HANGE , REMOV-
<br /> ALS
<br /> MOV-ALS and/or any other TANK INFORMATION CHANGE,
<br /> 2. This farm should be completed by either the PERMIT APPLICANT on the LOCAL.AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are.raking 3 copies.
<br /> . Tank owners most submit a plat plan to the kcal agency showing the location of the LISTS with respect
<br /> to buildings and landmarks(2711 (a)(3) CCR).
<br /> 6. Tank owners must submit documentation shoving compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs[2711 (a)(11) CCR),
<br /> TOP OF FORM: MARK ONLY ONE IT EM
<br /> 1, dark an (X) in the box next to the item that best describes the reason the fora is being completed.
<br /> 2. indicate the DEA or Facility name where the tank`is installed.
<br /> . TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID m If there is a tank number that is used by the owner to identify the tank(ex.
<br /> AR707S"3).
<br /> R. Indicate the name of the company that manufactured the tank(ex. ACME TANK FFG).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons (ex, 25,1360 or 10,000 etc.).
<br /> il. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box `l and complete iter$ F &C.
<br /> 2, It not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete Items S&Imo,
<br /> R. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<br /> D. Print the 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 /> Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, E, C & D
<br /> 1, Check only one item in TYPE OF SYSTEM,,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION.
<br /> 2. If OTHER, print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1 Circle"A" if above ground circle"U" if underground, and circle bath if applicable.
<br /> 2. 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 /> , TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED -MONTHNEAR (January, 19€6 or 611138)
<br /> . ESTIMATEDQUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED WITH INERT"MATERIAL? Check"Yes" or"No",
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS IND[-
<br /> ATED [see section 2711 a)(13) CCR)
<br /> INSTRUCTION FOR THE 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 count{and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(916)227-4303, The facility number must be the same as,
<br /> shown in form „A", The tank number may be assigned by the local agency, however,this nurnber must be numerical and
<br /> cannot contain i an alphabet,t, If the local agency prefers the State Board to assign the tank number, please leave!t blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL4 AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> ,LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK CO Y SHOULD BE RETAINED BY THE TANK OWNER.
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