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<br /> INSTRUCTIONS IO S FOP COMPLETING FORM-"Baa
<br /> GENERAL AL INSTRUCTIOi
<br /> Section 77tl'# ' title 23, Division ,Chapter 16, California Code of Regulations and sections 25286, 5287,and 25289
<br /> of Chapter,6.7,jDiyision 23, Health and Safety Code 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 CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION 1 .
<br /> 2, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making copies.
<br /> 5. Tank owners must submit a plot plan to the local agency showing the-location of-the US`s s with respect
<br /> to buildings and l ndmarks(2711 (a)(6)CCR).
<br /> 6. Tank owners rest submit documentation showing compliance with state ffianc(di respf � .1y"re require-
<br /> TOP
<br /> to the local agency for petroleum USTs(2711 (a)(11)CCR].
<br /> TOP F FORM: MARK ONLY ONE ITS
<br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is b9J-;-
<br /> 2.
<br /> Indicate the DBA'or Facility name where the tank is installed.
<br /> I. TANK DESCRIPTION - COMPLETE ALL ITEMS a IF UNKNOWN - SO SPECI ''
<br /> A. Indicate owners tank ID#w If there is a tank number that is used by the owner to ider, ., (ex.
<br /> AB70769),
<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 /> If. 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 co ple-49 iterns B&D.
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked iftA).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the ..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, S, C & D
<br /> A_ . , .Check only one item in E OF SYSTEM,TANK MATERIAL, INTERIOR LINING as JI CORROSION
<br /> ._PR®TEt�TION, _. . - .
<br /> 2. If OTHER, print in the space provided.
<br /> IVa PIPING INFORMATION
<br /> 1. Circle"A"if above ground circle"U"if underground, and circle-both if applicable,
<br /> 2. if UNKNON.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 r;y tem(s)used to comply with the monitoring requirements for the tank.
<br /> VL INFORMATION ON TANK PERMANENTLY NTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LAST USED'-'MONTHNEAR (January, 1933 or 0 1/83)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> . WAS TANK FILLED WITH INERTMATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MIDST SIGN AND DATE THE FORM AS INDI-
<br /> CATED (see section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The stateun er round 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 FIESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> „LOCALAGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW CC3PIS, THE PiNICSHOULDE RETAINED BY TiE TAS! €SER.
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