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INSTRUCTIONS FOR COMPLE10DI 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 /> I 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 /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENOY UNDER-
<br /> GROUNDTANK INSPECTOR,
<br /> 3, Please type or print clearly.all requested Inforrnation,
<br /> 4, Use a hard p*fnt writing.4sSt"Lin'rent,you are makinc
<br /> 13 copies,
<br /> 5, Tank owners must subrnitCl plot plan to the ocal agency showing the location of the UST's with respect
<br /> to buildings and fandrcarks[2711 (a)(8)CCRJ,
<br /> 6, Tank owners muwt submit docrimentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs[27111 (a)(11 t CC%
<br /> TOP OF FORMMARK ONi,.,y ONE ITEM
<br /> n-,",e o od.,to trif, t describes the reason the forn bein ompeted,
<br /> Mark an IX, in P" ;box na item the has, r � is go I
<br /> 2, Indicate the DSA or Facility name where thetank is
<br /> 1. TANK DESCRIPTION - COMPLETE AUL ITEMS - IF I UNKNCA%AJN - SO,' SPECIFY
<br /> A. r*nurnbe-rl t"iats;used by the owner 40 identify the tank(ex,
<br /> AS70789)
<br /> 8, Indicate thc, narne,, ciflhe -0ha tank (ex.ACME"TANK MFG),
<br /> C, Indicate the "'ank irlslaiiod 98-7j,",
<br /> IT. Indicate the tar* capac0hy In gGiors; (ex,25,000 or 10,000 etc,,
<br /> 11, TANK CONTENTS
<br /> A. 1. IF MO1r0R VEHICLE FIJEL, c;hed'k I ar,,�'J "On"plete iterns B&C,
<br /> 2, If notMOTOR VEHICLE F(JEL, v,,ppfopnste,box in section A and complete items B&D,
<br /> F3, Check me appropdate box,
<br /> Check the type of F(Je ff 1 is chucked in A),
<br /> D, Print the est isrnica: riarns,a,,"The: t-iaz""",rdou. .,,,,jbs,ance stored in the tank and the C,AS,#, (Chemical
<br /> Abstract Servit,,e rn_,,rr,,ber, �I box I is Nr,')T ,,,�neckr.r in A,
<br /> I'll, TANK CONSTRUCTION- MARK ONE ITEM ONLY IN BOX A, 6, C & D
<br /> 1. Check onl,,4,,one item in T`,./PE OF,`,.,YSTEfv1,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. If OTHER, print In the spaca; pmvIdett,
<br /> IV,
<br /> PIPING
<br /> t n, c`r-'-, —d-ro—und'I, and circlnth if licable.e bapp
<br /> Circle"A" it above gmJ �"4z `W if ug MM, ,,Q
<br /> f U N K N 0,W n LAI e 0 OT, E �J�SPcCl'i�,,Or ed,
<br /> RI)d 6,
<br /> 3mdicavafih.�,,.� LEAK a,
<br /> Vs"`s`rnis, used _-omp!y wilh the monitoring requirement far the piping.
<br /> V, TANK LEAK
<br /> `j, Indicate the'LEA', systemd;I used to comply with the monitoring requirements for the tank.
<br /> VI, iNPORMATION ON "I"ANK PERM0,,IENTL,,3i CILOSED IN PLACE
<br /> 11
<br /> , ESTIMATED DATE LAST UISED- MON"111-ifl(EAR (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZAIFID01,3S SUBSTANCE remaining in the tank in Gallons).
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL?' Check'Yes'or"No".
<br /> 'T,AJ,,JK OWNER OR A1..1-P-410IR"IZED REPRESEINTATIVE MUST' SIGN AND DATE THE FORM AS INDI-
<br /> CAl,"ED, [see section 2-11 11 (a'lli 3) CCi`-Q,1
<br /> Ii�,,,JSTI`QLJCTiON FOR THE LOCAL AG'rN'i",IE3
<br /> le state,underground storage tank digirdouhty number-Ithe three digit
<br /> june-dic,bon number,the sb�dig`rt`ha cifily number and the six1digit tank number,. The county and jurisdictiom,numbers are
<br /> predetermined and can be-obtained by callingtheStat,6-Bear,-*(916)227-4303,11'ho-facifity number must,be,,the same as
<br /> shown in fi,)rm"A", The'ank nUmber may be assigned
<br /> I , ,however,this number must be-numerical and
<br /> canric contain an aiphabet, I,,' 'he Prefers State ids,,,,,arr""I'a assign,,the tank number, please leave it blank.
<br /> IT IS TH.,E: RESPONSO'H.ITY OF THE LOCAL AGENCY T HAT INSPECTS 'THE FACILITY TO VERIFY THE ACCU-
<br /> R AC'�5r t F Tk E -HiLE I,.,O!,3AL AGEN("Y 6 FRSPC_N-0E P In THE COMPLETION OF THE
<br /> 0
<br /> '10CAL A,SENCY U t i',,«FORMXIION Ri,")X_, ""HE LOCAL A-2,_ENCY SHOUt-D RETAIN 'THE ORIGINAL AND
<br /> YELLOW ICOPIES. THE F"I"",,N'K, 1"r, SIHO(JI'D BE BY THE- TANK OWN IT,
<br />
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