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INSTRUCTIONS FOR COMPLET ING FORM
<br /> GENERAL INSTRUCTIONS
<br /> Sectron271 i ofTille23, Division 3, ChaPtE,r V13, Cao,,,,ia Code ofRegulations and sections 25286, 25287 and 25289
<br /> at Chapter 6.7, DMsion 20, He%afflri anK%CR
<br /> d Safa ,,'.)de ,'.4Uirs tank owners to apply for an UST operating perrnit,
<br /> tneORM "B" shaft be corn red fi, eadh tank €o all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/0' r any other TANK lNFCR'N,A`NON GHANGE. 1
<br /> 2, This form should be completed by e3 Per the PERMIT APPLICANT or the LOCAL AGENCY LINDER-
<br /> GROUND TANK INSPECTC)P,
<br /> 3, Please type c,,r print cleady,,a!I infornistion,
<br /> 4, Use a hard point v,rrfing y,,u are rnaking'Z3 copies,
<br /> Tank owncan,, mus �,-,,ubrrit a K)lol,Plan, c ths-,,,local -agency showing the location of the USTs with respect
<br /> to buildinosand" 12'711 (a)�3) CCRI,
<br /> 6, Tank ownerslrniist aulbrnit document,,,, ion showing compliance with state financier responsibility require-
<br /> ments to the local agency for petroleum USTs[2711 (a)(1 1) CCRIJ,
<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 tllank°rs installed.
<br /> L TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A, Indicate owners tank lD
<br /> if fl-lere is a tank ni,,imber that is used by the owner to identify the tank(ex.
<br /> A B-1 C)7,01
<br /> B, lnd'ca�(;1he name of the company t:na,, mnuflarcured'the tank (ex, ACME TANK MFG"
<br /> indicate the year the tank was instalk,�d ',ex, 1987).
<br /> D, Indicatethe tank capacn g
<br /> ity ialions 25,000 iO0
<br /> o� , 00 etc.),
<br /> 1! TANK CONTENTS
<br /> A, 1, iF MOTOR VEHICLE FUEL, rlees k'.'box 1 andcomplete Items B14,
<br /> 2� If not MOTOR VEI,ilCLE FiJEL,clneck the appropriate box in section A and complete items B&D;
<br /> 6, Check the appropriate box,
<br /> C, Check the type of MOTOR VEHrCLE FUEL(if box 1 is checked in A),
<br /> D. Pdritthe chemical name of the hazardorfk7su star�, e stored in the-tank and the C,A,S,#, (Chemical
<br /> Abstract Seis nunnbe,,), if 6ox I is NO'Tchiecked in A.
<br /> fli, TANK CONSTRUCTION ,-,7,v,1ARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1'
<br /> Check only one itein TYP-_ OF SYSTEM,TAN K MATERIAL, INTERIOR LINING and CORROSION
<br /> m c_
<br /> 2 If OTHER, print in the space provided,
<br /> IV, PIPING !NFORIMATION
<br /> pla'A" if above ground circle"U" ifunderground.. and circie both if applicable,
<br /> I Ci,
<br /> 2, If UNKNOWN circle; or if OTHER, print in space provided.
<br /> 3, Indicate the LEAK DETECTION systern(s) used to comply with the monitoring requirement for the piping,
<br /> VTANK LEAK DETECTION
<br /> 1s Indicate the LEAK DETECTION system(s)used to cof ply with the monitoring requirements for the tank.
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LASS US11"ED, (January, 1988 or 01/88)
<br /> 2, ESTWATE()QUANTITY of FIAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check "Yes"or"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 /> T he state underground storage tank identification nmb
<br /> umber is composed of the two digit county number, the three digit
<br /> jurisdiction number,the 'six digit faci5ty.runber and Ina six digit tank number. The QoLLnty aodjurisdict ion numb4�a are
<br /> predetermined and can be obtained by calling the State,Board.(916)227-4303. The facility number most be the same as
<br /> shown in form"A", The tank number may be assigned bey the local agency,however, this number must be numerical and ,
<br /> cannot conitain an alphabet, if ine local agency prefers the State Board to assign the tank number, please leave it blank,
<br /> �T IS THE-RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY-TO VERIFY THE ACCU-
<br /> H� t
<br /> RACY OF THS,, IFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> t0t, LISE ONLY' INFORMA—RON BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, 1"HE PINK SHOULD BE RETAINED BY THE TAN£ R.
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