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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 25286, 25287, and 25289 <br /> of Chapter 6.7, Division 20, Health and Safety Coda require tank owners to apply for an UST operating permit. <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT GRANGES, REMOV- <br /> ALS and/or any other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY LINDER- <br /> GROUND TANK INSPECTOR, . <br /> 3. Please type or print clearly all re Obsted-informatio'ri.`' <br /> 4. Use a hard point writing instrument, you are.making 3 copies. <br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect <br /> -- --._.to buildings and landmarks [2711 (a)(8)CCR]. <br /> . Tank owners must submit documentation showing compliance with state financial responsibility require- <br /> ments to the local agency for petroleum USTs(2711 (a)(11) CCR]. <br /> TOS' OF FORM. MARK ONLY ONE ITEM <br /> 1. hark an ( ) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DEA 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 /> 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. 1987). - <br /> D, indicate the tank capacity in gallons (ex, 25,000 or 10,000 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 chemicral 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, B, C & D <br /> 1. Check only one iters 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 doth if applicable. <br /> 2, If UNKNOWN circle; 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 system(s)used to comply with the monitoring requiremenTs for the tank. <br /> 111. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) <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 DATE THE FORM AS INDI- <br /> CATED (see section 2711 (a)(13) CCR] <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The stale underground storage tank identification number i 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)227-43013. The facility number must be.the same as <br /> shaven in farm "A". The tank number may be assigned by the local agency, however,this number must be numerical and <br /> cannot contain an"aiphabet.. If the local agency prefers the State Board to assign the tank number, please leave it blank. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACLU« <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 COPY SHOULD BE RETAINED BY THE TANK OWNER, <br /> r <br />