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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 25286, 25287, and 25289
<br /> of Chapter 67, Division 20D, r!Saf`,�t,,/C,,,-,,,de require tar l<owners to apply for an LIST operating permit,
<br /> 1 One FORi",.1 `B' be a fo,,each tank for all NEW PERMIT,-3, PERkll'T 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 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 must submit a plot plan to the local agency showing the location of the USTS with respect
<br /> to buildings and landmarks12711 (a)(8) CCR],
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<br /> 6, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to f1he local aaency for petroleum USI's [2711 (a)(1 1) CCR],
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate 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 company that manufactured the tank(ex,ACME TANK MFG).
<br /> C. Indicate the year the tank was installed (ex. 1987),
<br /> D. Indicate the tank capacity in gallons (ex, 25,000 or 10,000 etc,),
<br /> TANK CONTENTS
<br /> A. 1, IF MOTOR VEHICLE FUEL, ,hock box 1 and complete iterns B&C.
<br /> 2. if not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D,
<br /> E. Check the appropriate box,
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<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 CONSTRUCT ION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1 Check only one item in TYPE OF SYSTEM,JANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. If OTHER, print in the space provided,
<br /> IV. 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 systems" used to comply with the monitoring requirernent for the piping,
<br /> V, TANK LEAK DETECTION
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LAST USED- MONTHNEAR (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
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<br /> — WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS IND[-
<br /> CATED [see section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<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 ob,,
<br /> to ,ed by calling the State Board (916)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 contain an alphabet, If the to agency prefers the Stale Board to assign the tank number, please leave it blank,
<br /> IT IS THE RESPONSIBILITY, 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 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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