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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 25235, 25237, and 25259
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply fo, an UST operating permit,
<br /> 1= One FORM "B"shall be competed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any Bather TANK INFORMATION CHANGE.
<br /> 2. This form should be completed by either the PERMIT APPLICANT"or the LOCAL AGENCY LINGER_ '
<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 roust submit a plot plan to the local agency showing the Location of the USTs with respect
<br /> to buildings and landmarks (2711 (a)(3)OORj.
<br /> S, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs(2711 ( )(11') COR].
<br /> TCP OF FORM: HARD ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next to the items that best describes the reason the farm is being completed.
<br /> 2. Indicate the DBA or Facility name where the tanki's Installed.
<br /> I. TANK DESCRIPTION - COMPLETE ALL. ITEMS - IF UNKNOWN N - SO SPECIFY
<br /> A. Indicate owners tank I #- If there is a tank number that is used by the owner to identify the tank(ex.
<br /> A 70789).
<br /> 13, Indicate the name of the company that manufactured the tank(ex. ACME TANK FCS).
<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 /> IL TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, deck box 1 and complete items l3&O.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A,and complete items
<br /> E. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(€f 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 /> ical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> Ili. TANK CONSTRUCTION 7,MARK ONE ITEM ONLY IN BOX A, E,
<br /> 1._ Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> SION
<br /> _ PROTE TION.
<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 BEAK DETECTION system's) used to comply with the monitoring requirement for the piping,
<br /> V, TANK LEAD DETECTION
<br /> 1. Indicate the LEAD DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> tfl. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LAST"USED -'MONTH/YEAR (January, 13135 or 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS ARDOUS SUBSTANCE remaining in the tank(in Gallons),
<br /> 3. WAS TANK FILLED WITH INEPT"MATERIAL? Check„Yes" or"No",
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED,
<br /> N TI=CATEt [see section 2711 (a)(1 3) OCR]
<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 obtained by calling the State Board(215)227-430 . The facility number roust be the sauce as
<br /> shown in forms "A". The tank number may be assigned by the local agency,however,this number must be numerical and
<br /> cannotcontain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank,
<br /> IT"IS`THE RESPONSIBILITY OF THE Lo AL'`AGENOY THAT INSPECTS THE F'ACILIT'Y TO VERIFY THE ACCU-
<br /> RACY
<br /> LI®dA Y OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INFORMA T ION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL A i
<br /> YELLOW COPIES, THE PINK COPY SHOULD RE RETAINED BY THE TANG ()WNER
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