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INSTRUCTIONS FOR COMPLETING FORM "B" -
<br /> GENERAL INSTRUCTIONS
<br /> 8e(*n2711 of Title 23,Division 3, Chapter 16,California Code of Regulations and sections 25286,25287,and 25289
<br /> of Chapter 6.7,Division 20,Health and Safety Code require tank owners to app"r an UST operating permit.
<br /> 1. One FORM"B"shall be completed for each tank for a,If�PEAi�I(TS, PERMIT CHANGES, REMQV
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 2._' . This form should be completed by either the PERIJIT AP PILICANT or the LOCAL AGENCY UNQER-
<br /> ;. GROUND TANK INSPECTOR.
<br /> . 3.- Pleese,type or print clearlyli requested information. -
<br /> 4. Use a hard point writing instrument,you are makes 3 copies W.: :,, '-
<br /> _5. . Tank owners must submit a plot plan to the local age-4F►ovring the location of the USTs with respect
<br /> to buildings and landmarks[2711 (a)(8)CCR).
<br /> 6. Tank OWners must'submitdocumentation showing eoiripliancew-'ith state financial responsibility require-
<br /> ,r
<br /> - ents#o-the local agency for petroleum USTs[2741-(a)(11)CCR].
<br /> TBP -OF FORM. MARK-ONLY ONE ITEM -
<br /> „, rk ian(X)in;#he box next to the item-pest c ct s the form is being oomple#ed.
<br /> .2. Wicate the DBA or Facility name where the tank lOnstalled
<br /> TANK ,
<br /> DESCRIPTION - COMPLETE ALL ITEMS iF UNKNI ,, D _SPECIFY ;
<br /> A._ Indicate owners tank ID#-If there is-a tank-number that is use#yths-ownerto ideFftthe tank(e;r-.1.
<br /> AB70789)
<br /> B. -indicate the name of the company that mAnufactured the tank(e :ACME
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons(ex.25,000 br 10',000 etc.).
<br /> If. TANK'CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box."! and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items-e&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 ani,the C.R�S.�.
<br /> Abstract Service number),if box lis NOT checked m k--
<br /> Ill. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN X A, _Bt, C &"D'
<br /> g 1. Check only one item in TYPE OF SYSTEM,TANK,MA AIL,lNiTE, k.INING and CORROSION
<br /> PROTECTION.
<br /> 2. If OTHER;print in the space provided.
<br /> . 4 m
<br /> 1V.. PIPING INFORMATION !
<br /> 1. Circle"A47.if above ground circle"U*jf underground, �0# if a ie. .,
<br /> 2. If UNkk WN circle;or if OTHER,print in spacej rc>vided: b
<br /> }
<br /> 3. Indicate the LEAK DETECTION sysiem(s)used Womply with the mon g requir ent for the p ng.
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION$Ystemsused#a rwith#tqnonitoringrequirements
<br /> othe X
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED_#4.PLACE..
<br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988.1ir'01/88)
<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 AS. INDI,,,
<br /> CATED [see section 2711 (a)(13) CCR] -
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tooidentification numbers orpposed c the tw -digit cpunty number,the hreea i
<br /> jurisdiction number,the six digit facility number and the sii-digit.tw*nurnber. T'he counilr and)urisdictio". umbers are_
<br /> predetermined and car_,be obtained by calling,the State. ,j 3. The fadlity number must d=t i0 same-as :?
<br /> sho%i;in form"A". The tank number may be assigned by * however,this number must be numerical and
<br /> cannot contain an alphabet. If the local agency prefers the State Board to assign Ills tank number,please Ieave, ark.
<br /> ( IT-1S,THE RESPONSIM ITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE.;ACCU-
<br /> RACY OF THE INFORMATION. THE FOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE .
<br /> "LOCAL AGENCY USE ONLY" INFORMATION PDX' THE LOCAL AGENCY SI-OULD AtN THEGINAt--AND
<br /> K. "
<br /> YELLOW COPIES. THE PINK, SHOULL) BE R tNEb BY : °ANK NE€ " -
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