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INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter ,,6, California Code of Regulations and sections 25286, 215287, and 25289
<br /> of Chapter 6.7, Division 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 CHANG117.REMOV-
<br /> ALS and/or any other TAN 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 point 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 USTs with respect
<br /> to buildings and landmarks [2711 (a)"8) CCR`
<br /> 6, Tank owners must sr omit dOCUmentation showing compliance with state financial responsibility require-
<br /> ments,to the local agency for petroleum USTs [2711 1 (a)(1 1) CCRj,
<br /> Top OF FORM: MARK ONLY ONE ITEM
<br /> i Maa (X) in the box next to t�pits'rn that best deitdr�ibes the reason the form is being completed,
<br /> rk n _
<br /> 2, Indicate the DBA or Facility narrie where the tank i,S inst,,flled.
<br /> 1, TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID 4 - If there is a tank number that is used by the owner to identify the tank(ex,
<br /> AB-70789).
<br /> B, Indicate the name of the company that manufactured the tank(ex, ACME TANK MFG).
<br /> C, Indicate the year the'tank was installed (ex, 1937),
<br /> D. Indicate the tank capacity in gallons (ex, 25,000or 10,000 etc.),
<br /> IL TANK CONTENTS
<br /> A, 1, iF MOTOR VEHICLE FUEL, chock box 1 and complete items B& C.
<br /> 2, if nMVE
<br /> r=ot OT EH CLE 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 1 is checked in,A)i
<br /> D. Print the chemical name of the haza-,,dtus substance stared in the tark and the C.A.S.#. (Chemical
<br /> Abstr,,,,Act Service number), it box 1 is NCTclh-coke-d 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 /> IV, PIPING INFORMATION
<br /> 1, Circle 'A` ','I above oround circle, "U" €,f underground, and circle both if applicable,
<br /> 2, if UNKNOWN circle, or if OTHER, p[int 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 /> I indicate the LEAK DETECTION systern(s'luwed to comply with the monitoring requirements for the tank,
<br /> V1. INFORMATION ON TANK PERMANENT! Y CLOSED IN PLACE
<br /> ESTIMATED DATE IAS, USED - s„,Jl ONTI.-AiY EAR (JanL.laq,% 1988 or 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3, WAS TANK FiLLED WITH INERT N41ATERIAL? Check "'Yes”or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE 'THE FORM AS iNDI-
<br /> CATED [see section 2711 (a)(131) CORI
<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 /> prede-tarrnined and can be obtained by calling the State Board(9,16)227-4303, The facility number must be the same as
<br /> shown in form "A", The tank number maybe assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet.,If the loc4l agency prefers the State Board to assign the tank number, please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL 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 USE ONLY" INF AATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE Plied C OULD BE RETAINED BY THE TANK JAIWER,
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