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INSTRUCTIONS FOR COMPLEA FORM "B" 0
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division,3, Chapter 16,California Code of Regulationo and sections 3,23287,and2528, 9
<br /> of Chapter 6.7,Division 20, Health and Safety Code require tank owners to apply foran LIST operating permit,
<br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITIS. PERMIT CHANGES, REOV-
<br /> M
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 2This 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 info, natj' r ,
<br /> 4, Use a hard point writing instrument,you dre rnaking 3 d6pies.'
<br /> & Tank owners must subrnit a plot plan to the local agency showing the location of the USTwith respect
<br /> to buildings and landmarks[2711 (a)(8)CCRI,,
<br /> 6, Tank owner,%m submit documentation showing conipliance with state financial r ,soonsibility require-
<br /> ments-to the local agency for petroleum USTs 12711 (a)(1 1,)-COR),
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next to ft-ifern that best describes the reason the form is being completed,
<br /> 2, Indicate the DBA or Facility name where the tank is ipstalh9d,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> AIndicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank,(ex.
<br /> AB70789).
<br /> B, Indicate the name of the company1hat t,.,,,,nk(ex,ACME TANK MFG),
<br /> C. Indicate the ye ar the tank was installed (ax, 198"1
<br /> D. Indicate the tank capacity in gallons(ex.25,000 Or 10,000-tc,).
<br /> 11. TANK CONTENTS
<br /> A. 1. IF MOTORVEHICLE FUEL,check box 1 acomp
<br /> let colete items B&ON
<br /> 2. If not MOTOR VEHICLE FUEL,check the app ropriata box in section A and cornplete items B&D
<br /> B, Check the appropriate box
<br /> D. Check the type of M,�,,")TOR V,7'41,,`� I is cheaked In A).
<br /> D, Print the chemical name of the subst"Ance storedinl1he§ank and the .a,.S, (Chemical
<br /> Abstract Service number),if box 1. is A,
<br /> III. TANK CONSTRUCTION- MARK ONE IT ENI ONLY IN BOX A, B, C & D
<br /> 1. Check only one item in TEFF OF SYS3TEMI,TANK MATERIAL, INTERIOR LINING and CORROSION,
<br /> ,R�ROTECTJON,
<br /> 2'... 1VOTHER, print in the space providekt� ,,
<br /> 'V, PIPING INFORMATION
<br /> 1. Circle"A" if above ground a U"if UodlrgMLW,ad, and circle bbth if applicable.
<br /> 2, If UNKNO`WrJ circle-,or it,an-lEls, pdntir�si-zon prcwiced,
<br /> 3. Indicate the Lk-.AK used to compiy with the monitoring requrameat for the 'piping.
<br /> Ve TANK LEAK DETEC'I`1ON
<br /> 1, Indicate the'LEAK DETECTION system,,'I's)usedim cornply.with,. monitoring requirements for the tank,
<br /> V INFORMATION ON TANK 1'_1LC),oED IN, PLACE
<br /> 1. , ESTIMATED DATE LAST USED- l%,'O,,'1,'Tl1,f/Y_EAP (Januar, , 1988or011188)
<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 INDI-
<br /> CATED [see section 2711 (a)(1 3) CCR]
<br /> 'NSTRUCTION FOR THE LOCAL AGENCIES
<br /> I - n p digit�coun
<br /> i"stlate underground storage ta.- k identification nur,'
<br /> �bsr, is,�ma osed�joftbe tw ty,number,the t4w,"Aigit
<br /> iunsdict ion number,the six p digit faclifty �x
<br /> 'number and the, x dipit,tAnk nurn0r.,The county and jurisdiction numbers are
<br /> 9
<br /> red rmthed and can be a b t`a�'Inad by d9l I ng the Statz.-,Tlcnz,rd(0, 16)2-7-430"r`.TIm tacl I ity-num bar must by the samea al"s-
<br /> showninform"A", The tank number may be assigned bythe locai agency,however,this number most be numerical and ,
<br /> 46annot contain an alphabet, I', the local agency prisfer fl, 9 'Ssltate Boair-d,to assign the tank run-nbsr, pIease 10,ave it blank,
<br /> IT.IS THE RESPONSIBILrTY OF THE LOCAL AGENCY THfflr IsISFECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INF 6hMATICSN. THE LOCAL AGENCY Is RESPONSIBLE FOR THE COMPLETI N OF THE ,
<br /> "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER,
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