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INSTRUCTIONS EOR CAS �LETING ORtvt "R„
<br />GENERAL INSTRtd" l0pit;
<br />Section 2711 of Title 23, Division 3, Chaptcir ' '.California Code of Regulations and sections 25236, 23237, and 25239
<br />of Chapter 3.7, Division 20, He ftlh and Sa eir,, Code requiro tank owners to apply for an LIST oDeratingpermit.
<br />1. One FORM "B"shall be for mach tank for all NEW PERMIT S, PERMIT CHANGES, REMOV-
<br />ALS and/or any other TANK INFORMATION CHANGE.
<br />2. This fora should be completed by eith r the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br />GROUND TANK !NSPEC"
<br />3,
<br />N ER -
<br />3. Please tyle or prin.,t clearly °,al' ;C ue, ;ed information.
<br />;:tion.
<br />i.'
<br />. Use a hard point writing instrument, you arra making 3 copses.
<br />3. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect
<br />to buildings and landmarks (2711 (a)(3) CCR].
<br />S. Tank ow ners must submit documentation showing compliance with state financial responsibility require-
<br />ments to they local agency for petroleum USTs (2711 (a)(1 1) CCR],
<br />TOP OF FORM: MARK ONLY ONE ITEM
<br />1. furls an ( in the box next to the stern that best describes the reason the form is being completed.
<br />2. Indicate the DBA or f=acility name where the tank is installed.
<br />I,
<br />TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOW - Sid SPECIFY
<br />A. Indicate owners tank ID ff . If there is a tank number that is used by the owner to identify the tank (ex.
<br />A 570733 ).
<br />E. Indicate the name of the company that rnanufactured the tank (ex, ACME TANK MFG).
<br />S. Indicate the year they tank was i m.a lc ,d (ex. 1987) 1
<br />11. TANK CONTENTS
<br />A. 1, IF MOTOR VEHICLE P=fit` check box 1 and complete items 3 C.
<br />2. If not i TOR VEHICLE FUEL, check the appropriate box in section A and complete Items E & E,
<br />3, Check the appropriate box.
<br />C, Check the type of MOTOR VEHICLE CLE FUEL (if box 1 Is checked in A).
<br />D. Phrst the chemical name of the haaardou'a substance stored in the tank and the C.A.S. . (Chemical
<br />T
<br />Abstract Service number), if box 1 is N checked in A.
<br />M., TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, B, C
<br />i. Check only one items in TYPE OF SYSTEM, TA KMATERIAL, INTERIOR LINING and CORROSION
<br />PROTECTION,
<br />2. If OTHER, print in the space provided,
<br />1, Circle "A" if above 11round circle .,LI" ie underground, and circle both if applicable.
<br />2. If UNKNOWN circle; o, if OTHER, print in space provided.
<br />3, indicate the LEAD DETECTION syste n(s:) used to comply with the monitoring requirement for the piping.
<br />Vv TANK LEAD DETECTION
<br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank,
<br />V1. INFORMATION ON TANK PERMANENTLY CLOSED IN .PLACE
<br />1 ESTIMATED DATE LAST USED - MON HNEAR (January, 1335 or 01/35)
<br />2, ESTIMATED UAI TIT'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br />3, WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or" o".
<br />TANK OWNER OR AUTHORIZED ORI E REPRESENTATIVE t UST SIGN ANIS DATE THE FORM AS INDI-
<br />CATED
<br />? -
<br />AT ED (see section 2'711 1a)(1 31 CCRI
<br />The state underground", storage tank identification number is composed of the two digit oour;t7 number, the three digit
<br />jurisdiction number, the six digit facility number and the "six digit tank number. The county and jrarisdiction numbers are
<br />predetermined and can be obta 3 red by calling the State Board (916" 227-4303, The facility number must be the same as
<br />shown in form. "A".Tine tank nikr"r be. ,tom" y be assigned by the local agency, however, this number ber mut be numerical anis
<br />cannot contain an ale.,..a bcat, If he local i e g nc ,fe es fief._« St aue Board o a,4nsian the tank number, please leave i blank,
<br />IT IS THE RESPONSI31LITY OF THE LOCAL AGENCY THAT'INSPECTS THE FACILITY TO VERIFY THE A U -
<br />RACY' -.GE. THE INFORMATION, ATION, TRE 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 Go SHOULD BE RETAINED 3Y THE TANKNER.
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