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<br /> INSTRUCTIONS FOR COMPLETING FORT 'B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23; Division 3, Chapter 16, California Code of Regulations and sections 25266, 26267, and 23239
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit.
<br /> 1. One FORE "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHALICES, REMOV—
<br /> ALS and/or any ether TANK 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 /> 6. 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)(6)CCR).
<br /> 6. Tank owners most submit documentation shoring compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs(27 31 (a)(11)CCRj.
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. hark an (X) in the box next to the Item that gest describes the reason the form is being completed.
<br /> 2. Indicate the I9SA or Facility name where the tank is installed.
<br /> I. TANK DESCRIPTION ® COMPLETE ALL ITEMS m IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank I[ m If there is a tank number that is used by the owner to identify the tank (ex,
<br /> AR7939).
<br /> Indicate the name of the company that manufactured the tank(ex, ACME TANK MFG),
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons (ex. 25,000 or 13>903 etc.),
<br /> II. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items E & C,
<br /> 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items S& 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 the hazardous substance stored in the tank and the C.A.S.#t. (Chemical
<br /> Abstract Service number), if box 1 is N CST"checked in A,
<br /> Ill, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN SOS; A, R, C & S
<br /> 1, -.Check only one item in TYPE OF SYSTEM, TANK MATERIAL,I,AL, INTERIOR LINING and CORROSION
<br /> PROTECTION.
<br /> 2, If OTHER, print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1: Circle"A"if above ground circle "U" if underground, and circle both if applicable,
<br /> 2: If UNKNOWN circle; or if OTHER, print in space provided.
<br /> Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION sykern(s)used to co ioly with themonitoringrequirements for the tank,
<br /> VI, INFORMATION ON TANK PERMANENTLY CLOSELY IN PLACE
<br /> 1. ESTIMATED BATE LAST USED m MONTH,,YEAR(January, 1936 or 01/88) `
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes" or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS IND6
<br /> CATER [see section 271 (a)(13) CCR]
<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"jutisdicti6n numbers are
<br /> predetermined 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 may,be assigned by the local agency, however,this number nest be numerical and
<br /> cannot contain an alphabet. If the local 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.N. T"E LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" IN4HOULD
<br /> ATION BOX. THE LOCAL AGENCY SHO*RETAIN
<br /> RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK C BE RETAINED BY THE TANK R.
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