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IRTRL TT 1 FCR COMPLETING FOR "B"
<br /> EN AL'INSTRUCTIONS
<br /> Se-ion 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25266,26267,And 26289
<br /> df h pter 6,7,Division 20, Health and Safety Code,require tank owh4ri:6;dpofy for arsIS r tin (t.
<br /> !. FORM "B"shall be,co pleted for each tank for all NEW PSR I`T ,;PERMIT #A GE �
<br /> ALS and/or any other TANK INFORMATION CHA G . . .
<br /> 2. This form should be com lr t d t
<br /> her the PER AT.ADPL l AIT �the LOCAL.AGENCY UNDER,
<br /> 'GROUNDTANK IPE TR.
<br /> . Please type or,print clearly all requested information;
<br /> 4. Use a bard point writing instrument,you are making 3 W;.,
<br /> & T=ank owners must submit a plot plan to the local agencyshowin4tho Idosition of the USTs'-,Mth,r p" .
<br /> o buildings and landmarks(2711 ( )t0) )
<br /> 6. Tank owners must submit documentation showing complinc Ith statefinancial raspy ,�>t�i ity regtli
<br /> meats to the local agency for petroleum U T°s(271 (a)(1 V R]
<br /> TOP OF FORM. MARK ONLY ONE ITEM
<br /> 1-;,, -Mark an
<br /> , Q0,Jinthe box next to the item,that best ddscri eTpAsoni !the
<br /> form is beim g.
<br /> 2Andicat .thy DBA or Facility name where the tank4 Installed:
<br /> . TANK I' LL CIF's
<br /> A. Indicate owners tank I �#a If ere is a tare num �at�i Ias d y� b .n rtb oder��';.V
<br /> A 7078 ),
<br /> B. Indicate the name of the company that manufactutod,the tank(,ox.-ACME TANK MFG=
<br /> C. Indicate the year the tank was installed(ex.'1987).;
<br /> D. Indicate the lank capacity in gallons(ex,25,000 or 10,000 etc.).
<br /> II. TANK CONTENTS
<br /> 1. IF MOTOR VEHICLE RL,check box 1 andsomplete items C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriatein section A and complete Items D.
<br /> B. Check e appropriate box.
<br /> . Check the o of MOTOR VEHICLEF (if box 1 is checked in .
<br /> D. Print the chemical name of the hazardous substance stored in the tankand e ,A. . . (Chemical
<br /> Abstract Service number),if box 1 is checked in A.
<br /> Ill. TANK CONSTRUCTION- MARK ONE ITEM ONLYIN 9OX A,,:, ,'
<br /> 1, Check only one item in TYPE OF SYSTEM,TANKAT IAL, IIT I LININGarse#; RRI I
<br /> PROTECTION.
<br /> . if OTHER,Print in the space prodded,
<br /> IV. PIPING INFORMATION
<br /> 1. Circle W if above ground circle"U"it ander roun A and circle both if applicable.
<br /> . IfNiK circle;or if OTHER,,print In space Provided'.
<br /> . Indi to the LEAK DETECTION system(s)used to so",with monitoring requirement for e 'l .
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate,the'LEAK 'TIS syst rn(s)used to comply with,themonitoAng,.requirements fortha t4hk.
<br /> VI. INFORMATION TANK A E TLCLOSED ,IN PLACE
<br /> 1. ESTIMATED DATEMONTH (Janna ,f99 or °111 )
<br /> 2. ESTIMATED,QUANTITY of HAZARDOUSZUBSTANCE remaining in the tank(inGallons),
<br /> . WAS TANK FILLED WITH INERT MATERIAL? heck" ss` '"N0 -1
<br /> A � T H IIS REPRESENTATIVE S I �A k b DATE,THE, A ' INDI
<br /> TED (sue 4ectlion,2711 (a)(11 3)CCR]
<br /> !NSTIAU ON
<br /> 1y . . "LOCAL AGENCIES
<br /> .,
<br /> The'state underground storage tank identification n mb r is comp;' d df tt e#fid' i at county number,the three digit
<br /> jud i ton n rr bari the Ali digit facil` number r and e si `git n h�zrhber e coon and judsdiction nurnbars are
<br /> tormined rs and e obtained b i a State a (91 � 7 3 rti m r enrist e
<br /> h `" Ih forrh$'A".e..°t)? t hk n'' er may sign d, y the Ibc l gees t d s r#tlil risr r rns st 0€ rrieri I d
<br /> "canript,containanalp,habet. 1f the local agency prefers,the State Board to assign: be tank k number,please leave It blank,
<br /> IT IS,THE, RESPON,811SILITY OF THE LOCAL AGENCY THAT INSPECTT H4 :`PA&IUTY TO RIFy TH V1 ,
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RF I LF F •THE COMPLETION,OF THE
<br /> ,: .; i "tX ' NLY11'INFORMATION AT`I < THE .S ALA 1� ' � U`I . t TRF I #NAL A
<br /> LL.:" AhIb t ." "
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