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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 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 INFOl"ONIATFON CHANGE.
<br /> P
<br /> 'PLICANT or the LOCAL AGENCY UNDER-
<br /> 2. This form should be completed by either the PERMIT Ai
<br /> GROUND TANK INSPECTOR,
<br /> 1 Please type or print clearly all requested information.
<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 /> buildings and landmarks(2711 (a)(8)CCR].
<br /> 6. 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 /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next,to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is'll-istalled.
<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 /> IL 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 /> III, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 71. 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 both if applicable.
<br /> 2. If U N KNOA,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 /> I Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement s for the tank.
<br /> V1. 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 /> 1 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 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
<br /> bit tank nunibeir. Thb county drid juNsdiction 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 maybe assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet. If the local ag6ncy 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 ACCU-
<br /> I�ACYQF,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.
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