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INSTRUCTIONS FORIr P*11_ ; , F "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chanter to 10, California `ot and e� is s � � 1,.87 �
<br /> Iter � ,���x��� �� �'���^, �z
<br /> f Chapter 6,7, Division 20, Health and Safety Code require e t nk owners to apply for an
<br /> 1. One FORM"B"shall be completed for each tank for ll NEW PERMITS,, MIT CHANGES, E t(T,,
<br /> ALSand/or any other TANK INFORMATION CHANGE.
<br /> . This form should be completed by either the PERMIT UCA!N T or the AGENCY UNDER-
<br /> GROUND TAN
<br /> i E -
<br /> Uf INSPECTOR,
<br /> d, Please type or print clearly all requested information.
<br /> Use a hard point writing instrument,you are making 3 copies.
<br /> , Tank owners moat at;bm t a plot plant to the local agency showing the location of the ,`rsltxlth respect,
<br /> to buildfngsancf landnmrks(27,11 (a)(8)CCR)
<br /> p T nk-pwo rs_,.,t Admit dr crtm rrtati rr showing compliance itlh,state .1r?:N,,, aJ r..ribility require-
<br /> ments,to the , .:. ;;y for petroleum UST (271 t (a)(1 1)CCRI,
<br /> 1, Dark an (X) in the box next ,co the item that best describes the reason the form is being completed.
<br /> p.
<br /> Indicate or 1 r llRtt .; r: n the teak is installed.
<br /> L TANK DESCRIP"i'lON - COMPLETE AU_ 'PI-EME), - IF 'UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank 1D 1t there is a tank number that is used by the owner to identify the tank ,
<br /> B7 89),
<br /> �
<br /> r ., ,sr : € � t� , l TANK
<br /> 1t�Indic,
<br /> CIndicate the year xr;�,,s instafled (ex. 987",
<br /> , Indicate the to k; �pM citta} in g .fl.on 7 (ex,.''25,00:,`G o, ;0,00,0 , -
<br /> Il, TANK CON a;F F, I
<br /> , 1. IF MOTOR VEI AX_L I y box 6 an,11 connpt ate items s&C.
<br /> . £ of.�r r a�� ° .v:t. ':° r!s, Isom" section and complete items B& ,
<br /> If rase#+t9 ,.VEHICLE,_�. �; ...,�,,k,.���na,.[.�,..� '� z ,
<br /> , Check the aper pr ,,..s box.
<br /> 0.
<br /> Ch k P1r.;�ryt �` Tt 1 is checked in ),
<br /> D, Print the chemical name of ,a stored lin thetank and the n. , . _(Chemical,
<br /> Abstract S t, b,86" , a. 4 - 1,. n A,
<br /> $ll, TANK CONSTRUCT!, N 'CJI F,`K ON,",' �..�m ri,.. BOX A, B,
<br /> _r r . �1, Check only aie � � MATERIAL, r E I LINING and CORROSION
<br /> PROTECTION,
<br /> p. It OTHE
<br /> , t<.:s the..'ace
<br /> lv� PIPING
<br /> i, Circle"A" ,s above gr i.i"rrul s e �� � �,.� � � .... a.a �f g�iml �>R If r�ppal��l 19. ,
<br /> I Utl G-r, ,C..slk , s,xs P, 3 bt�,a ss;t �a�. pro video.
<br /> Indicate h L, >K D',.,TE IO :I 4 ';ref °F kr_, comply with the monitoring r quir ment for the piping,
<br /> V, TANK LEAK DETEG1FN','),N1
<br /> 1, Indicate the LEAK D T r I N sy..tswm(s)used t o rnrliv with the monitoring Ismuir rnenta for the task,
<br /> L IN TON1IN TANK P .RMANEN 1 L' CLOSED IN PLACE
<br /> 1, ESTIMATED DA-s LAST ` Ea° (January,1988 or 01/ , )
<br /> ESTIMATED QUANTITY I etr I.f a a i ,:-,,,, ff SUBSTANCE remaining"sr q ire thetank fin Gallons).
<br /> Cl WAS TANK FI .LF... tri r a ERT KI ,1H y ("In k':(' Yasr,or N6
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE rfILI T SIGN AND DATE THE FORT Ars INDI-
<br /> CATED
<br /> N ICATER section 2711 (a)(!3) SCR)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number 'is composed of the two digit county r;trr ,ber, the three digit
<br /> rrrl dl tirarr lIl 4 C,the g dSyxt laci it},r`;rrmbe thefix r"gr,tank number. The county Arad jurisdiction numbers are,
<br /> preddt rmirfad and can be obtained dy calling the Stake ,oaraf(91 d)22-` -4303, The facility number must be the sears as
<br /> shown in farina"A". The tank number may by assigned by tl, lbcal agency,however,this number mast be numerical and ;
<br /> cannot contain an alphabet, 'if the local agency prefers the ,:terra Boars to assign the tank dumber, lease leave it blank,.
<br /> IT IS THE RE f? N IBILIT Y OF TIFF. LOCAL AGENCY TH,'-,T INSPECTS THE FACILITY TO VERIFYTHE ACCU-
<br /> RACY .I Ffl1Tr.t. TI N, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ,r.�r" INFORM TION BOX, THE LOCAL GEN SHOULD RETAIN ,l�xE FiIGINA�. N
<br /> ° ;l,�LOVV.at, b . THS Pli,13 t: COPY SHOULD BE IET TINED BY HE TANK 9AfNER,
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