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INSTRUCTIONS FOR COMPLETING FORM „B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25266,25267, and 25259
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit.
<br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE,
<br /> 2, This fora should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard paint writing instrument, you are making 3 copies.
<br /> 5. Tank owners rnust submit a plot ploys to the local agency showing the location of the LISTS with respect
<br /> forbuildings and landmarks(2711 (a)(B) CCR].
<br /> 6. Tank owners must submit docume elation showing compliance with state financial responsibility require-
<br /> ments teethe local agency for petroleums USTs(2711 (x)(11) CCR],
<br /> TOP OF FORM, MARK ONLY ONE ITEM
<br /> 1. Mark an ( ) in the box next to the~.item that best describes the reason the form is being completed.
<br /> 2. Indicate the LISA or Facility name where the tank its installed.
<br /> 1. TANK DESCRIPTION - COMPLETE .ALL ITEMS m IF UNKNOWN - SCI 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 /> AB70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG),
<br /> C. Indicate the year the tank was installed (ex. 1/337).
<br /> D. Indicate the tank capacity in gallons (ex. 25,000 or 19,000 etc.),
<br /> II. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL.., check box 1 and complete items B& C,
<br /> 2: If not MOTOR VEHICLE FUEL,check the appropriate:box in section A and complete items B&D.
<br /> B. 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 /> 111, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, 6, C & D
<br /> 1. Check only one itern in TYPE OF SYSTEM, TAT 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 both if applicable.
<br /> 2. If UNKNOWWcircle; or if OTHER, print in space provided.
<br /> 3. 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 systern(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 - MONTHIYEAR (January, 9966 or 01/68)
<br /> 2. ESTIMATED QUANTITY 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 ELATE THE FORM AS INDI-
<br /> CATED (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 county 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 number must be numerical and
<br /> cannot contain an alphabet, If the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> IT IS THE RESPbNSlt3lLlTY�OF THE L06A AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> Qy: 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 COPT` SHOULD BE RETAINED BY THE TANK OWNER,
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