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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, 25267, and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit.
<br /> 1. One FOR "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHA GES, 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 aro making 3 copies.
<br /> 5. Tank owners must submit a plot plant to the local agency showing the location of the U STs with respect
<br /> to buildings and landmarks (2711 (a)(8)CCF?].
<br /> 6, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum RISTs (2711 (a)(1'1) CCE,.
<br /> TCO ' OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next td the item that gest describes the reason the form Is being completed,
<br /> 2. Indicate the€ BA or Facility name where the tank'is installed.
<br /> I. TANK DESCRIPTIO - COMPLETE ALL ITEMS - IF UNKNOWN - SCO SPECIFY
<br /> A. Indicate owners tank I #W If there Is a tank number that is used by the owner to identify the tank(ex,
<br /> AE70759},
<br /> S. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFC),
<br /> C. Indicate the year the tank was installed(e . 106711,
<br /> D, Indicate the tank capacity in gallons(ex.25;000 or 10,636 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,check the appropriate box in section A and complete items B& D,
<br /> B. 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 /> III. TANK CONSTRUCTION .; MARK ONE ITEM ONLY IN BOX A, S, C & D
<br /> 1, Check only one item in TYPE OF SYSTEM,TANK 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 bath if applicable,
<br /> 2. If UNKNOWN circle; or if OTHER, print in space provided.
<br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V1 TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to corhply with the monitoring requirements for the tank,
<br /> V1. INFORMATION ON TAKES PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED GATE LAST USED MO THNEAP (January, 1053 or 01,£38)
<br /> , 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 COIF AUTHORIZED REPRESENTATIVE E f IUST SIGN AND DATE TIME FORM AS INDI-
<br /> CATED (see,section 2711 (a (13) CCE(
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification nurnbr is composed of the two digit county number,the three digit
<br /> jurisdiction nurriber, 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(9,16)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 /> can sot contain an alphabet, If the local agency prefers the State Board to assign the tank number, please leave it blank,.
<br /> 1TAS. TETE 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 COSILY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN TETE ORIGINAL AND
<br /> YELLOW COPIES, TETE PINK C PY SHOULD BE RETAINED BY THE TANK NEER.
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