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INSTRUCTIONS FOR COMPLE* FORM "B" 46
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Divisior',, 3, Ch,,-ipter 16, California Code of Regulations and sections 25286, 25287,and 25289
<br /> of Chapter 67, Division 20, Heath and Saf t,
<br /> y Code require tank owners to apply for an L1,31'operating perrmiL
<br /> 1 One FORM "B" shall be completed for each tank fOr all NEW PERMITS, PERMi"r CHANGES, REMOV-
<br /> ALS and/or any milher TANK INFORMATION CHANGE.
<br /> 2, This form should be completed by either the PERMIT APPLICANTor the LOCAL AGENCY UNDER-
<br /> GROUND TANK it,1SPEC-11"OR
<br /> 0, Please type pr4it 6-i-,arly all requested inforinnal"'tork.
<br /> 4Use as hard point writing inatru=ent,you are fnak-Ing I copies,
<br /> 5,. Tank ownersmuubmit a plotolan to the local agency showing the location of the Us with respect
<br /> to buildi,ngs 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)(1 1) 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 installed.
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A, Indicate owners tank ID 4 -it there is at,,;ink number that Is used by the owner to identify the tank(ex.
<br /> AB70789),
<br /> B, Indicate the narnc,,,,,jf fiae the,tank (ex,ACME TANK MFG),
<br /> C, Indicate the year thf.,,,Tank,v, as instailed (ex. 19,
<br /> lg, Indicate the tank capacity in gallons (ex,25,000 or 10,000 etc,).
<br /> I L TANK CONTENTS
<br /> A, 1. IF MOTOR VEFflCL,1` FUEL, cl-lecilk box " and complete items B&C.
<br /> 2. If not MOTi OR VEHICLE FUEL, check the appropriate box hi section A and complete items B&D
<br /> B. Check the map proprlbox
<br /> CCheck the type(,,,,,f N1C`.,,-1Of4 VEHI,1C'i_,EFUE,L(if box I is checked rn A),
<br /> D, Print the chemical name o"Ithe haat ardou,,,,s substance stored in the tank and the CA.S.#, (Chemical
<br /> Abstract Service mumber), it box 1 is NO"t'checked in A.
<br /> III, TANK CONSTRUC-1-ION- MARIK, ONE ITEM ONLY IN BOX A,
<br /> -V ' ANK MATERIAL, INTERIOR LINING and CORROSION
<br /> Check onlyone item in 7 (PE OF SYSTE�vi,T
<br /> PROTECTION,
<br /> 2, If OTHER, pn-,"n the scene pnov-ded,
<br /> ilv� PIPING INFOFF.Mit Ak"TIre
<br /> N
<br /> 1, Circle"A" if above ground it under,,groUnd, and circle both if applicable,
<br /> 2, If UNKNOWN 03`rlff,�,"R --ir-
<br /> Spac:,, provided,
<br /> n
<br /> sw, the monitoring requirement for the piping.
<br /> 3, Indicate the 1J",",AK oen usedto comply win
<br /> V, TANK LEAK DETEC"I"i0i\l
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> V1, 'INFORMATION ON TANIKPEI-'Nu,,A1AN'E�NTLy CLOSED IN PLACE
<br /> 4� It ED -lN-,,1ON"H/YEAR (January, 1988 or 01/88)
<br /> 9 ESTIMATED DATE t,ASTUSE"
<br /> 2, ESTIMATED QUAyiTITY ofHAZARD01LIS SUBSTANCE remaining in the tank in Gallons),
<br /> 3, WAS TANK FIU El',),`0/iTH I1,!NEFTAF [ERIAL? Cho,41J ck"Yes'or"No",
<br /> I ANK OWNER OR AUTIHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [seesection 2711 3) CCRJ
<br /> INSTRUCTION FOR T HE LOCAL AGEEZINICIES
<br /> a state widerground sfor aq, nurnber is composed of the bee digit county number,the three digit
<br /> jurisdiction number,the sixdigit f cilihqnumber and the six digit tank number. The county and Jurisdiction numbers are
<br /> predaternnined 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 nurn.,ber may be assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet, if the in"cal agency preft,,vs the State Board to assign the tank number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF 1'HE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORNiATIage . -1 HE LOCAL AGENCY iS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE OM-Y` �INFORMATION BOX, TH,,E LOCAIL AGENCY SHOULD RETAIN 'THE ORIGINAL AND
<br /> YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER.
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