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INSTRUCTIONS FOR COMPLETING FORM `B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit,
<br /> One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV.
<br /> ALS and/or any other TANK iNFORI'VIATION CHANGE,
<br /> 2. This fora should be completed by either the PERMIT APPLICANTor the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> !l
<br /> Please type or print clearly all requested Information,
<br /> A. Use a hard point writing instrument, You are making 3 copies,
<br /> 5. Tai-* )v,,n„,rs must suarnit a plot plan to the !,coal agency showing the location of the USTs with respect
<br /> to buildiings and landmarks[2711 (a"(8)CCRI
<br /> 6Tank owners must subrnit documentation showing compliance with state financial responsibility require-
<br /> mems to the local agency for petroleum USTs [2711 (a)(1 1) CCR],
<br /> TOP OF' FORMMARK ONLY ONE ITEM
<br /> 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 /> 1. TANKDESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID # - It there is a tank number that is used by the owner to identify the tank (ex,
<br /> A670789),
<br /> E. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG),
<br /> C. Indicate the year the'tank was installed 'l x. 1987),
<br /> DIndicate the tank capac I fly in gallons (ex. 25,000 o� 10,000 etc.),
<br /> 11, TANK CON1-ENTS
<br /> A. 1, IF MOTOR VEHICLE FUEL, check box 1 and complete- items B& C.
<br /> 2, If not MOTOR VEHICLE FUEL, check theappropriate box in section A and complete items 6&D.
<br /> B� Check the appropriate box,
<br /> C, Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<br /> D. Print the chemical name of Itne hazardous substance stored in the'fank and the C.A,S.#. (Chemical
<br /> Abstract Service nurnber`�, if box I is NOT checked in A,
<br /> Ili. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> I —
<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, Chile"A” if above ground circle "U" if undergroury
<br /> d, and circle both if applicable.
<br /> 2, if UNKNOWN circie; or if OTHER, print in space provided,
<br /> 3. Indicate the LEAK DETECTION systerrits, used to comply with the monitoring requirement for the piping,
<br /> Va TANK LEAK DETECTION
<br /> ,d cmply with the monitoring requirements for the tank.
<br /> i Indicate the EAK DETECTION systE-�rr i(s) usc'ito o
<br /> VL INFORMATION ON -TANK PERMANENTLY CLOSED IN PLACE
<br /> 1 ESTIMATED DATE LAST USED - MONTHiYEAR i'January, 1288 or 01/88)
<br /> 2. ESTIMATED QUANT 1TY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> 1 WAS TANK FILLED WITHINERT 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",(l M CCRI
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification nurnber is composed of the two digit county number,the three digit
<br /> jurisdiction number, the six digit facility number and the sik digit tank number, The county and jurisdiction numbers are
<br /> pre cle4-grInined 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 maybe assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet, If the loop,[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 T HE 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" INFO MAT ICN BOX, THE LOCAL, AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE FGHOUL D BE RETAINED BY THE 'TANK (IMER,
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