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II TR CTIONS FOR COMPLETING F H '"B'
<br /> GENERAL,INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,CaliforniaCade of Regulati'ons and sections 25256,25257,and 25259
<br /> Of Chapter 5.7,Division 20, Health and Safety Code require tank Iry t ` plal f r an LIST operating,permit,
<br /> I. One FORM "B"shall,b completed for each t nk'fdr all NEW PERMITS,PERMIT CHA ICES, E.M =
<br /> ALS and/or any other TANK INFORMATION CHANCE„
<br /> 2. This form should be completed by either the PERMIT APPLICANT L:ICANT car the LOCAL AG15NC UNDER-
<br /> GROUN TA IIC INSPECTOR.
<br /> . Please type or print clearly allrequested Infer tion.
<br /> 4. Use a hard point writing instrument,you are making 3,cdpiee. �
<br /> 5. Tank crura must submit a plot plan to the local Agency,showirilthp location of the USTith tet
<br /> .
<br /> t btriiing hd Iarr arks(2711 (3)CCRI,
<br /> 6. Tania owners roust submit documentation showing,compliance with` t tai financial respan..ibility require-,:,
<br /> menta to the local agency for petroleum U Ta(2711 ( )(I i)CCPJ
<br /> T F FORM:" L E ITEM
<br /> 1. ark air )Aftthe box next td the item that bestdoscribes,the-ripason the form is bei
<br /> 2.1 4nd1t : A or Facility name where the tank is Installed.
<br /> 1, TANK DESCRIPTION - COMPLETE ALL IT 4IF UNKNOW SO SPECIF� '
<br /> A. Indicate own rs tank 1 D#v I If there I a a tank numb r th At l �J aiad by the ownisr td rd r td*.
<br /> 707 ).
<br /> B. indicate the name of the company that manufactured the tank( x;.ACME TANK MFG"
<br /> Ca Indicate the year the tank was Installs ( . 1
<br /> D. Indicate n capacity in gallons( x.25,000 or 1.0,060 etc.).
<br /> ll® TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete,items B&C.
<br /> . If not MOTOR VEHICLE ICLE EL,check the appropriateox in section A and comp4ete items B&D.
<br /> B. Check the appropriate box.
<br /> C. Check the typeof MOTOR VEHICLEFEL(if box I is checked-in, ).
<br /> D. Print the chemical name,of the hazardous substance stored irr the tank and the C,A.S. .(Chemical
<br /> Abstract Saari number),if box,! -is NOT chacka 'in A.
<br /> IIIc TANK CONSTRUCTION ffi MARK ONE ITEM ONLYIN, BOX A,. , C
<br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTER16A LINING NG And CORROSION ',,,
<br /> PROTECTION.
<br /> 2. tf OTHER,print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1. Circle'A"if above ground circle OU"if underground,and circle bo if applicable.
<br /> 2. if UNKNOWN circle;or if OTHER, print in space prldd.
<br /> 3. Indicate the LEAK DETECTION system(s)used to ornpl ; ith %monitoring requirement for ter :pi 1,
<br /> V. TANK LEAK T CTI
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply witty the monitoring requirements1for ttl tank,
<br /> I, INFORMATION TANK PERMANENTLY CL I
<br /> 1. ESTIMATED,DATE LAST USE -MONTHfYEAFI t riu r �198 1 . s=
<br /> ,z
<br /> 2. ESTIMATED UANTI of OUS, t SSTANCE'r rnalnirlg,� :.. t
<br /> �
<br /> n . : :
<br /> 3. WAS'TAMC FILLED WITH INERTMATERIAL? C ebk'- a�or N
<br /> TANK OWNER,,ORD REPRESENTATIVE MUST, SIGN
<br /> .° THE FORM AS INDI-
<br /> CATED
<br /> AT'E [sae section 2711 ( )(13) CCR] i
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state under rn nd storage tank identification number 1a oro da d'of the d,digit county number,the three digit
<br /> jurisdiction number,the six digit facility number and the ai digit tank number'. Tlho-6ouhty,and jurisdiction numbers are
<br /> predetermined and can be obtained calling the State Board(91 ) n clI' r rads b e rr'#6 as
<br /> shd 'irr'fo *A". tank number may be assigned by the Io 1. g,`.: 7' ro re this'number must be numerical and
<br /> cannot centaur an alphabet. If the local agency prefers the State Board4o assign tank number,please leave It blank.
<br /> IT IS,THE RESPONSIBILITY,OF THE LOCAL AGENCY THAT E4 S E T ,.,T =,: ,FACILITY TO VERIFY THE ACC
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR,THE OMPLETION OF THE
<br /> "LOCAL,AGENCY USE ONLY" INFORMATION BOX. THE LOCAL'ASE ` � iN THE.�C 1 1NAl`
<br /> ELLC CFfES, THE 'PINK SHOULD ERETAINED BY:TW,TA: 114
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