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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 UST operating permit.
<br /> 1. One FOR "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/car any other TANK INFORMATION CHANGE,
<br /> 2. This form 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 r6quested 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 /> .I to buildings and landmarks(2711 k'a)(8) CCR].
<br /> 6. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petro'eum USTs(2711 (a)(11) CCR].
<br /> ,TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1._ Dark an ( ) in the box next to the item that best describes the reason the foram is being completed.
<br /> 2. Indicate the IBA or Facility name where the tank is installed.
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank IO#f- If there is a tank number that is used by the owner to identify the tank(ex._
<br /> AB76789),
<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, 1967),
<br /> U. 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 S& C.
<br /> 2. If notMOI—OR VEHICLE FUEL,check the appropriate box in section A and complete items B&O.
<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 stared 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 RUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & IS
<br /> 1. Check only one items 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 around circle"U„ if underground„ and circle both if applicable.
<br /> , 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 DE=TECTION
<br /> 1, Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank.
<br /> V1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED CRATE 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 MATERIALS 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 identifications 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 a
<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 tri alphabet,, 1f the€ocaI 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 /> .Y CIF; 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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