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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 25266,25237, and 25269
<br /> of Chapter 6.7, Division 20, Health and Safety Code 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 CHAN ES, REMOV-
<br /> ALS and/or any other 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 /> 5. Tank owners mst submit a plot plan to the local agency showing the location of the UST s with respect
<br /> to buildings and landmarks(2711 (a)(3)CCR].
<br /> 6, T=ank owners must submit documentation showing compliance with state financial resp,� ibiiify require-
<br /> ments to the local agency for petroleum USTs(2711 (a)(11)CCR].,
<br /> TOP OF FORM: MARK ONLY ONE ITW
<br /> 1. Mark an( ) in the box next to the item that best describes the reason the torm is be, -,,,,
<br /> 2. Indicate the DBA or Facility name where the tank i installed.
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN a SO SPECIFt
<br /> A. Indicate owners tank ID#- If there is a tank number that is used by the owner to ide. (ex.
<br /> AB70769).
<br /> Indicate the name of the company that manufactured the tank( x. ACME TANK MFG
<br /> C. Indicate the year the tank was installed(ex. 1967).
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).
<br /> IL TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and cosr pl to items E
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked iqi-A),
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.: ,#, (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> III. TANK CONSTRUCTION -,WRK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1 -_ -check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING .,=WI CORROSION
<br /> - PROTECTION.
<br /> 2, If OTHER, print in the space provided."_
<br /> ISI. PIPING INFORMATION
<br /> 1, Circle`°A"if above ground circle"U"if underground,and circle both if applicable,
<br /> . If UNKNOWN circle;or if OTHER, print in space provided.
<br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TALK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTIONsystem(s)used to cdmply with the monitoring requirements for the tank.
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE m -
<br /> 1. ESTIMATED DATE LAST USED-a^ ONTHNEAR(January, 1966 or 01/88)
<br /> . EST"IMAT"ED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> 3. WAS TANK FILLED WITH INERTMATERIAL? Check"Yes"or"Noy".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a)(1 S) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES R
<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 /> predetermined and can be obtained by ceiling the State Board(916)227-4303. The facility number must be the some as
<br /> shown in torr ' ". The tank number may be assigned by the local agency,however,this number must 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 /> c IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFOFIMATION, THE 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 C#& SHOULD BE RETAINED BY THE TANK _NER.
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