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INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division , Chapter 16, California Code of Regulations and sections 25266, 252137, and 26289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit,
<br /> 1. One FORM „B£,shall be completed for each tank for all NEW PERMITS, PERMIT CFIAN(ES, 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 TAMC INSPECTOR,
<br /> 3 Please type or print clearly all-requested information.
<br /> 4. Use a hard paint writing instrument,you are making 5 copies.
<br /> 5. Tank owners must submit a plat plan to the local agency showing the location of the USTs with respect
<br /> to buildings and landmarks [2711 (a)(6) CCRI.
<br /> Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs [2711 (a)(11) CCR],
<br /> TCT OF FORM; MARK ONLY ONE ITEC
<br /> 1. Mark an (X) in the box next to tile' 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 /> I. TANK DESCRIPTION m COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ICS#m If there is a tank number that is used by the owner to identify the tank(ex.
<br /> AB70739).
<br /> B, Indicate the name of the company that manufactured the tank(ex,ACME TANK MFC).
<br /> C. Indicate the year the tank was installed (ex. 1967).
<br /> U. Indicate the tank capacity in gallons (ex,26,060 or 10,000 etc.).
<br /> IL 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&U.
<br /> B. Check the appropriate box,
<br /> C. Check the type ofMOTOR 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, E3% C
<br /> 1. /heck only one item in TYPE OF SYSTEM,,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PdOTECTICON.
<br /> 2. If OTHER, print in the space provided.
<br /> ISI. 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 /> 1 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 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- h ONT [YEAR(January, 1966 or 01183)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 1 WAS TANK FILLED WITH INERT MATERIAL? Check"Yes'or"No".
<br /> TANK COINER OR AUTHORIZED REPRESENTATIVE MUST" SIGN-AND [GATE TIME FORM AS INDI-
<br /> CATED [see section 2711 (a)(1 S) CCR)
<br /> INSTRUCTION FOR THE LOCAL. AGENCIES_ _ T
<br /> t �
<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(916)227-4303. Thb°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 Mate Board to assign the tank number, please leave it blank,
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS TRE FACILITY TO VERIFY TIME ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INFO MATIOI BOX. Til LOCAL AGENCY SH U RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK C SHOULD BE RETAINED BY THE TANK t, ER.
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