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INSTRUCTIONS FOR COMPLETING FORM "B"
<br />GENERAL INST UC1_!ON ;
<br />Section 2711 of Title 23, Division 2, tv ha '' I2; California Code of Regulations and sections 25286, 25287, and 25289
<br />of Chapter 6.7, Division 20', Ho...h and `, h, . ode require tank owners to apply for an _QST operating permit.
<br />1 One FORM a i ren cc,'- eid ior each tank for all NEW P ERMl it , PERMIT CHANGES, REMOV-
<br />AILS and/or any other TANK INFORMATION ATION CHAN E,
<br />2. This fora should be, cornphetied by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br />GROUND TANK INSPECTOR.
<br />1 Please gape or print.clearly all requested information,
<br />4. Use a hard point writing instrument, you are making S copies.
<br />. Tank owners artist submit ra. plot plan to theU local agency shoeing the location of the Ts with respect
<br />to buildings and, la"Marks`2711 (a) C `) rig.
<br />. Tank owners rrr..l t su Zrnft documentation showing compliance with state financial responsibility require-
<br />ments
<br />€ quirem nts to the local agency for petroleum USTs (271 t (a)(t t) CCR]. ;
<br />TOP OF FC Ma MARK ONLY ONE ITEM
<br />1. Mark an (X) in the box next to the item that best describes the reason the forma is beim completed.
<br />2. Indicate the DBA or Facility name where the tank is installed.
<br />L TANK DESCRIPTION - COMPLETE ALL ITEMS m IF UNKNOWN - SCS SPECIFY
<br />A, Indicate owners tank I - If there is a tank number that is used by the owner to identify the tank (ex.
<br />AB70789),
<br />E. indicate the name :)f the company that manufactured the tank (ex. ACME TANK MFG),
<br />. Indicate the year the tank was installed ex. 1987).
<br />U. Indicate the tank capacity in gallons ex. 25,000 or 10,000 etc,).
<br />IL TANK CONTENTS
<br />A. t, IF MOTOR V,._H,. LE FL)EL. h . 'k boy t and r. omolete items Lt & C,
<br />2. If no, Mt,a`7OR VE F11ICLE FL)E L ; check the appropriate o# riate box in section A and complete items B &
<br />B. Check the appropriate box.
<br />U. Check the type of MOTOR E fI LE FUEL (if box t is checked in A).
<br />D. Print the chemical name of the hazardous substance stored in the tank and the ,A. .##. (Chemical
<br />Abstract Service number), if tarn "I is NOT checked in A.
<br />Ill. TANK CONSTRUCTION N m MARK ONE ITEM ONLY IN BOX A, R, C & D
<br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION
<br />ROTE TIf N,
<br />2, If OTHER, print in the space provided.
<br />IV. PIPING INFORMATION
<br />1. Circle "A" if above ground circle „U.3 if underground, and circle bath if applicable.
<br />2. If UNKNOWN circle; or if OTHER, print in space provided. _
<br />1 indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br />V, TANK LEAK DETECTION
<br />t . Indicate the LEAK DETECTION systems used to comply with the monitoring requirem rats for the tank,
<br />X11, INFORMATION CTI TANK PERMANENTLY CLOSED IN PLACE
<br />. ESTIMATED DATE LAST USED ;'MONTHNEAR (January, 1988 or 01188)
<br />2. ESTIMATED QUANTITY of HAZARDOUS DOUS SUBSTANCE remaining in the tank (in Gallons).
<br />S. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes„ or "No".
<br />TANK A OWNER OR AU I4t.. RIZE'D ~b.,. PREESr-.�aN i i lye.:.. MUST SIGN AND DATE 'THE FORM AS INDI-
<br />CATED
<br />NDIWCAE [see Section 21-11 (a',03) Ci.aR]
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The state underground storage tank identification number is composed of the too 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 (9,16) 227-4303. The facility number Heusi be the same as
<br />shown in form "A", i ;, ,al, -!,k nul i t er r ,s 7 be assk--ime<i1by ti" e !oca'.l agency, show er, this nunnber must be numerical and
<br />cannot contain an aph L.;t, ., the v0cwi at, emq p,,,efers the State Board to assign the task number, please leave it blank,
<br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE AD U-
<br />tA Y. OF, THE INFORMATION, THE LOCAL AGENCY 1S RESPONSIBLE FOR THE COMPLETION OF THE
<br />'LO AL AGENCY USE ONLY" INFORMATION BOX. TIME LOCAL AGENCY SHOULD DETAIN THE ORIGINAL AND
<br />YELLOW COPIES, THE PINK U* SHOULD BE RETAINED Y THE TANK 16
<br />NER.
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