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> STFiU.,CTIONS FOR COMPLETING FORM'"B"
<br /> .. CMA
<br /> 1' INSTRUfTjgltlS ►` : ;� `
<br /> 711 of Title 23;Division 3,Chapter 16,California Code of Regulations and sections 25286,25287,and 25289
<br /> er 6.7,Division 20;Health and Safety-Coda m�iire tank owta"Voply for an UST operating permit.
<br /> I.- -One FORM"B"shall be completed-for`pilon tank for all I)1"E11V PERMITS.,FEFIMIT CHANODS, REM,.OV-
<br /> _ ' A'L'S and/or any other.TANK INFORMAT16N CHANGE.
<br /> 2.' "is-form-should be completed by either the PERMIT APPLICANT-or the LOCAL AGENCY NPER
<br /> GROUND TANK INSPECTOR.
<br /> Please type of print,cleacly all requested information.
<br /> `
<br /> y ...,..��....
<br /> 4. Use a hard point writing instrument,you are making 3 copies..
<br /> 5. "Tank owners must submit a-plot plan to the local agency showing the-location"of the USTs with respect
<br /> _16 buildings and landmarks[2711 (a)(8)CCR}.
<br /> 6. Tank owners must submit documentation showing compliance litiRstate financial responsibility-require-
<br /> M. .. --..ments to ft4ocal agency for petroleum USTs[2711 (a)(11) CCRI,.
<br /> ._o
<br /> TOP-OF FORM-: MARK ONLY ONE ITEM
<br /> - 1 Mark an (X)i the box.rwd to the item fat b€Ist _ s the m rih form is being,completed.
<br /> x x DBA or Facility name where the tank is-installed'Indicatethe
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN" $0-SPECIFY
<br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to ide,"th tank( ,
<br /> AB70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG)..
<br /> "r 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 /> 11. TANK CONTENTS
<br /> f,
<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 it1 A'
<br /> Ill. TANK CONSTRUCTION-MARK ONEATEM''ONLY IN'B& A, i3, C'& D y
<br /> 1 -..;:Check only one item in TYPE OF SYSTEM,TAME-MATE�AL, INTER16R"LINiNd and-CORROSION
<br /> PROT
<br /> G"T1(3N:
<br /> if 0THER;-p`rint in the space pnavideri. _ _.
<br /> ,,-1�tPINGANFORItatATION
<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 LEAK DETECTION systems)used to comply with the monitog'— requirement for the piping:
<br /> V TANK-LEAK, DE4CTION
<br /> _
<br /> I. IrxWate`"tEAK`DETECTION systems)iced to comply with the monitoringloquirements torthe tank._
<br /> 4 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE_, .,. . .
<br /> 1. ESTIMATED DATE LAST USED-MONTHIYEAR (January, 1988 or 41'!88)' _.
<br /> 2. 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 OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM �►5-`INDi-
<br /> GATED [see section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank-iidentification number is composed of the two digit,couhty number,the three"digit
<br /> jurisdiction number,the six digit facility number and the six tligit'tank number, The county and jurisdiction numbers ate
<br /> predetermined and can be obtained by celiing the State Board(916)227-4303. The facility number inust be the-same as:`
<br /> shown in form"A". Th
<br /> o1iink number May be assigned by the local agency,however,this number must be`numedcal and
<br /> cannot contain an alphabet -Iff the local agency p elers-the State Board to assign the tank number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF.THE LOCAL AGENCY THAT INSPECTS THE-FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION, THE LOCAL AGENCY 1S RESPONSIBLE FOR THE�,COMPLETION OF THE
<br /> "LOCAL-AGENCY USE ONLY" INFORMATIOWBOX THEI"- ?CAL AGENCY SHOULD"RETAIN THE ORIGINAL AN�'
<br /> YELL I;;gPI,ES. 'THE PINKRE NED aY,THE TAN NER
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