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INSTRUCTIONS FOR COMPLAG 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 FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, 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 UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> 3. Please type or p4ot clearly all requested inforrnation.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> 5. Tank owners must submit a plot plan to the tocaf agency showing the location of the USTs with respect
<br /> to 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)CCRj.
<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 /> I. TANK DESCRIPTION - COMPLETE ALI- 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 /> S. Indicate the name of the comparrli that m,-nufactured 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 /> 11. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, cheCK LJX° I and complete items B&C.
<br /> Z If norMOTIOR VEHICLE FUEL,cheok tTe appropriate box in section A and complete items B&D.
<br /> Bs Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(it box I 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 I is NOT checked in A.
<br /> Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. If OTHER, pdnt in the space provided.
<br /> sV, PIPING INFORMATION
<br /> 1. Circle"A"if above ground circle"U'if underground,and circle both if applicable.
<br /> 2. If UNKNOWN circlo-.or if OT HER, print in space provided.
<br /> 3. Indicate the LEAK DETECT'1011,11system"s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETFIC__" e
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> VL 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"car"No",
<br /> 'TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a)(1 3) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> i he state underground storage tank identification number is,,-omposed 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 and(916)227-4301 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 RESPONSIBILITY 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 /> "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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