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<br /> INSTRUCTIONS FOR COMPLETING FOR "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, Reath and Say at,,:Code require tare owners to apply for an UST operating permit.
<br /> 1. One FORM "B r I gall be r c ,° ted for each tank for all NEW PERMIT S, PERMIT CHANGES, REMOV-
<br /> ALS arid/or any other TANKNFOR TI CHANGE,
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECT(1)R,
<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 must submit a plot plats to the local agency shoeing the location of the USTs with respect
<br /> to buildings and landmarks [2711 (a)(8)CCR(.
<br /> 8, Tank owner r-n est submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum UST [2711 (a)(11) CCR].'
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, Mark ars (X) in the box next to"the items that best describes the reason the form is being completed.
<br /> 2. Indicate the[SBA or Facility name where the tank I is installed,
<br /> I, TANK DESCRIPTION N - COMPLETE ALL ITEMS - IF UNKNOWN - SCS SPECIFY
<br /> A, Indicate owners tank ILS f- if there is a tank number that is used by the owner to identify the tank(ex.
<br /> A7378B).
<br /> B. Indicate the name of the company that manufactured the tank(esu. ACME TANK MFG),
<br /> C, Indicate the year the tank was it stalled (ex. 1987),
<br /> B, Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.).
<br /> II. TANK CONTENTS
<br /> A, 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL,ch dR the appropriate box in section A and complete items B&B.
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A).
<br /> U. 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 its A.
<br /> M. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. Check only one iters in TYPE OF SYST '>TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2, If OTHER, print in the space provided.
<br /> ISI. PIPING INFORMATION
<br /> `I. Circle„A„if above ground circle EeU"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 LEAD DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED LATE LAST"USED - MON T HYYEAR (January, 1988 or 01/88
<br /> 2, ESTIMATED-Q ANTITY of HAZARDOUS SUBSTANCE remaining its the tank (in Gallons).
<br /> 3. WAS TANK PILLED WITH INERT"MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> GATED [see section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number Is composed of the tvgo digit county number, the three digit
<br /> jurisdiction number,the six digit facility number and the six digit task number. The countyand jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board( 16)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 must be numerical and
<br /> cannot c nta,ri an alphabet, lithe e local agency prefers 111;e State Board to assign the tank number, please leave it blank.
<br /> 1T IS THE RESPONSIBILITY-,OF THE LOCAL AGENCY `I`t-itis INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF TIME INFORMATION, 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 PINES COPY SHOULD BE RETAINED BY THE TANK OWNER.
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