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<br /> INSTRUCTIONS FOR CCSPE-11-ING FORM "B"
<br /> v
<br /> GENERAL INSTRUCTIONS
<br /> S
<br /> Sec i n 27 1$ o f T 2tl C 2 q Di v.Jii ,1 3< Cl ia .t..,it 6£ Iif rnjSr� tJSc Vf Regulations
<br /> ila iJay sections 25286, 25287, and 25289
<br /> of Chapter 3.7, Division 20, Health and Safalry Code require tank owners to apply iy fo an E CIS T operating permit,
<br /> 1, One FORE "B" shall ll be coma ped for each tarn for all NEW P.""'R ITS, PERMIT CHANGES, RFMCV-
<br /> ALSrand/or any other TANTS INFORMATION CHANGE.
<br /> .
<br /> 2. This form hould be completed by either the PERMIT APPLICANT or the LOCAL AGENCYUNDER-
<br /> GROUND
<br /> 3. Please type or print clearly all requested nested Information,
<br /> . Use a Bard point writing Instrument,you are making 3 copies.
<br /> . Tank owners roust submit a. plot plan to the local agency showing the location of the t1STs with respect
<br /> to buildings and landmarks(2" 11 (a)(3) CCR).
<br /> . Tank owners rnust submit documentation showing compliance with estate financial responsibility require-
<br /> ments to the local agency for petroleum USTs(2711 (a)(11) CCR).
<br /> TCF' OF FORM: MARK ONLY GNF `fiTEM
<br /> 1. Mark an (X) in the face,next to the iter,,that best describes the reason the form is being completed.
<br /> 2, indicate the 6A or Facility name where the tank is installed,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN w CG 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 /> A7 0789).
<br /> S. Indicate the name of the company that manufactured the tank(ex, RCAF TANK MFG),
<br /> C. Indicate the year the tank was installed (ex. 19137).
<br /> C. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc,'
<br /> C. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items IS&C,
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete`sterns B&C.
<br /> R. 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, . . (Chemical
<br /> Abstract Service number), if box 1 .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, print in the space provided.
<br /> V. PIPING INFORMATION
<br /> 1. Circle"A" if above ground circle"U"if underground, and circle doth if applicable,
<br /> . If UNKNOWN circle; or if OTHER, print in space provided.
<br /> ided.
<br /> 1 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 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 m MONTHNEAR (January, 1988 or 01F98)
<br /> 2. ESTIMATED ATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the rank (in Gallons),
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No",
<br /> TANG OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND SATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a)(13) CCR
<br /> INSTRUCTION FOR THE IF LOC;AL., AGENCIES
<br /> The state underground storage tank identification number is composed Lf the two digit county number, the three digit
<br /> urisdiction'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 Roptd(916)227-4303. The facility number,,rust be the same as
<br /> shown in f ro „A` The tank number-ma
<br /> y be assigned by the local agency,however,this number must be numerical and
<br /> cannot con airs n alphabet. If the lo�cNpency p of rs the State Board to assian the tank number, please leave it blank,
<br /> $—TH RESPONSIBILITY �F THE LOCAL"A ��) T THAT T INSF ..0 s SHE FACILITY TO VERIFY THE ACCN-
<br /> RAC Y OF TI IE INFOR A T ION, TF1 LOCAL AGENCY lS RESPONSIBLE FOP i 'L COMPLETION USF THE
<br /> "LOCAL AGENCY USE NLY" INFORMATION N ECX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE RINK CORY SHOULD BE RETAINED BY THE TANTS CANER.
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