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0 INSTRUCTIONS FOR S MPL4 FOS "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286,25257, and 25289
<br /> f Chapter 6,7, Division 20£ health and Safety Sade require tank owners to apply for ars UST 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 /> Z This farm should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY LINDER-
<br /> GROUND TANK INSPECTOR,
<br /> Please type or print clearly ali requested infe'7rroati n.
<br /> 4, Use hard point writing instrument,you are making 3 copies.
<br /> 3.. Tank owners must submit r a piot plea to the local agency showing the location of the LISTS with respect
<br /> to buildings and landr-narks(2711 (a)(3)SBSS(.
<br /> S,. Teak owners mut subrnitdocumentation showing compliance with state financial responsibility require-
<br /> ments to the Intal agency for petroleum LISTS(271 (a)(1 1)CCRjx
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, stark an ( in the box text to the iters that beat describes the reason the form is being completed.
<br /> 2, Indicate the DBA or Facility name where the tank is installed,
<br /> I, TANK DESCRIPTION COMPLETE ALL ITEMS - IF L N ` I - SO SPECIFY
<br /> , Indicate owners tank, IMAM" if th r�. .s n,A i k number that is used by the owner to identify the tank(ex.
<br /> S737ttt3).
<br /> S. Indicate the narne of the,company that manufaclklured the tank(ex,ACME TANK MSS),
<br /> Se Indicate at the year the tank vvaa installed ( x, 1387),
<br /> qg
<br /> D. gygp Indicate the tank capacity in gallons (ex.25,000 r 10,000 etc,),
<br /> IL TANK CONTENTS
<br /> 1. IF MOTOR VEHICLE FUEL, check bots 1 and complete items S&C.
<br /> 2. If not MOTOR VEHICLE E FUE heck the appropriate box in-section A and complete horns S&D,
<br /> S. Check the ap t.op to box,
<br /> S. Shtick the type of r.a. 3 $ V,,,.81.„1_'E r ur"'L iI,Dox 1 is checked int }.
<br /> D, Print the chemical nar,e�of fihe haz ar'r uz,,substance stored in the tank and the t3. 4S, , (Chemical
<br /> Abstract Servic r i,.zf3"bei), if box € is NOT checked in Aa
<br /> IIL TANK CONSTRUCTION-MARK ONE ITEM ONLY IN SOX A, S, S & S
<br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, I TE I R LINING and CORROSION
<br /> SI
<br /> PROTECTION,
<br /> 2,,1 If OTHER, print in thA space provide
<br /> iv,, PIPING INFORMATION
<br /> , Circle"A" if above ground circler"if underground,and circle both if applicable
<br /> tt, f UNKNOWN circle; if OH0a print it, spaceprovided, s,
<br /> 3. Indicate the LEAK Liu E r ION systernfs f used to comply with the monitoring requirement for the piping,
<br /> a TANK LEAK 5ETE:T r„f
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply ith the.momit rig requirements for the tank.
<br /> s .
<br /> €a INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1: ESTIMATED DATE LASTUSED-MO HI (January, 1988 or 01/88)
<br /> 2, ESTIMATES QUANTITY of HAZARDOUS SUBSTANCE r mainingin the tank(ire Gallons),
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes" r" ",
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE DEIST SISI AND DATE THE FORM AS INDI-
<br /> CATED
<br /> I-SATED (see section 271 (a)(1 3) CCR]
<br /> INSTRUCTION FOR THE LOCAL GSNC3oES
<br /> state
<br /> underground storagei Itank identification number ariscomi5oied of the two digit county numt!ibrbae three digit
<br /> jiurisdiction number,the sbdigit f rate r urnb r and the ix digit tank number. The county and jurisdiction numbers are
<br /> predetermined and fan be obtained by sailing the State Board(91 6)227-4303; The facility number must be the same a
<br /> shown in form� ", The tank number may be assigned,by the local agency
<br /> however,this number must be numerical and
<br /> cannot contain an alphabet, £, tt w�1 51agpncy p ( ta the riitate Board to assign the tank rtr ,b I leave it blank.
<br /> IT 1S THE RESPONSIBILITY O .tyro LOCAL, ro i T 'T 11 S STS THEIL1T 1 THE t3L1-
<br /> RACYOF THE INFORMATION, THE I
<br /> COAL AGENdY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INrORk,/ r IO BOX. THE LOCAL AGENCY SHOULD RETAIN THE 1 i L AND
<br /> 'YELLOW COPIES. 'THE PINK t.,OPY LH/.1t1LD SS ITLT 11£1St BY THE TANK Wt SS,
<br />
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