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INSTRUCTIONS FOR COMPLETING FORM "B`
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Tire 23, Division 3. 11-11-ispler 16. California Code of Regulations and sections 25236,25257, and 25289
<br /> 0 WCh-p �7
<br /> DMsk,)n 20, Health and Safety Code require tank owners to apply for an LIST 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 print clearly all requested information,
<br /> 4, Use a hard pcirA writing instrument, you are making 3 copies,
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the LISTS with respect
<br /> to buildings and landmarks [2711 (a)(8) CCR].
<br /> & Tank owners Must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs [2711 (a)(11) 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 /> L TANK DESCRIPTION - COMPLETE ALL 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 /> F. 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 /> 11, 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 complete items B&D.
<br /> B, Check the appropriate box.
<br /> C, Check the type of MOTOR VEHICLE FUEL(if 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 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 /> IBJ. PIPING INFORMATION
<br /> 1. Circle"A"if above ground circle "U" if underground, and circle both if applicable,
<br /> 2, If UNKNOWN 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 SyStern(S) used to comply with the monitoring requiremahts for the tank,
<br /> Vt. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED-,MONTHiYEAR (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining'n 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)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground 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 RESPONSIBILITY OF THE LOCL 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"USEONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE,ORIGINAL AND
<br /> YELLOW COPIES, THE PINK C,* SHOULD BE RETAINED BY THE TANK#NER.
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