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<br /> INSTRUCTIONS FOR COMPLETING ORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 13, California Code of regulations and sections 25288, 25287, and 25285
<br /> of Chapter 8,7, Division 20, Heafth and Safety `ode require tank owners to apply for an LIST operating permit,
<br /> 1. One FORM "F shall be r fed for each tank for all NEW t Ir'2,RMIT wS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other T NK!NF RM TICLt CHANGE.
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> N E -
<br /> GROUN TANK INSPECTOR.
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a Lard point writing instrument,you are making 3 copies.
<br /> 5. Tank owners asst submit a plot plan to the loom agency showing the location of the I.1 Ts with respect
<br /> to buildings and landmarks (2711 (a)O CCRj.
<br /> 8, Tank bwvers must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency to.,,,petroleum USTs 12711 (a)(1 1GC
<br /> TOP OF FORM: . RK ONLY ONE iT f',
<br /> 1. Mark an ( in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DSA or Facility name where the tangy is installed.
<br /> I. TALK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID#m If there is a tank number that is used by the owner to identify the tank(ex.
<br /> 70782).
<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 (ex. 1287).
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 18,038 etc.).
<br /> ll. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL, .her r`thd appropriate box In section A and complete items E&E
<br /> E. Check the appr=opriate box,
<br /> C. Check the type of MOTOR VEHICLE FUEL (If box i is checked in ).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical
<br /> ,abstract Service number), if box 1 is NOT checked in A.
<br /> Ill. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, S9 C
<br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL,IAL, If TERIO LINING and CORROSION
<br /> PROTECTION,
<br /> 2. If OTHER, print in the space provided.
<br /> Ill. 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 /> 3. Indicate the LEAK DETECTION systern(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> 1. in itiate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> 1. INFORMATION N TANK K PERM NE TLY CLOSED IN PLACE
<br /> 1, ESTIMATED LT TE LAST USED- MONTH/YEAR (January, 1988 or 81188)
<br /> 2, ESTIMATEDQUANTITY of HAZARDOUS SUBSTANCE remaining In the tank (in gallons).
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No",
<br /> TANK OWNER CP AUTHORIZED REPRESENTATIVE MUST SIGN AND LATE THE FORM AS !N I-
<br /> CATED (see section 2711 (a)(1 3), CCP]
<br /> INSTRUCTION FO€ THE LOCAL AGENCIES
<br /> mS
<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 calling the State Board(3`15)227-4333. 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 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 /> IT IS THE RESPONSIBILITY ITY OF THE LOCAL AGENCY THAT INSPECTS THE 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" INFORMATION SOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TALK OWNER.
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