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INSTRUCTIONS FOR COMPLOG FOR "B"
<br /> GENERAL. INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25256,35267, and ,29'
<br /> of Chapter 6.7,Division 20,Health and Safety Code require tank owners to apply for an UST operating p -,,it''
<br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, 1F �,11" CHANG NGES, R t��, .
<br /> ALS and/or any other TANK INFORMATION CHANGE,
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the i-OCAL AGENCY UNDER-
<br /> GROUND tANK INSPECTOR.
<br /> R.
<br /> . Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> . Tank owners must_submit a plot plan to the local agency shoring the location.o the USTs with respect
<br /> r to buildings and landmarks(2111 ( )(S)CCR].
<br /> 6. "Tank owners must submit docmentation showing compliance with state f nasi iall require-
<br /> ments to the local�,zgencv for petroleum STs I`271 (a)(11)CCR
<br /> TOP OP FORM: I ARI I' L ONE 11 EM
<br /> 1. Mark an ( in the box next to the item that best describes the reason the form is being completed.
<br /> . Indicate the DBA or Facility name where the tank is,i stailed. w
<br /> 1. TANK DESCRIPTION - COMPLETE AIL ,s F S - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank IDI - If there is a'Va a, nu b-r that is used by the owner to identify the tank(ex.
<br /> A!370789).
<br /> Indicate the name of thea company,,'hat rn,... ufactured the-tank(ex.ACME TANK MFG),
<br /> Indicate the year tank w as installed (ex. €987),
<br /> D. Indicate the n �f��,nm ys in F,,.II ns(ex. or ,00
<br /> Il.
<br /> TANK TENTS
<br /> 1. IF MOTOR VEHICLE FUEL, a ick hoar yx and complete items R&C.
<br /> . If not MOTOR VEHICLE FUEL, he aN, appropriate to box in sectionA section. and complete items
<br /> B. Check the appropr tai box.
<br /> Chock the . of k, f` l V,.,!°i1,Ct_ (0, r cx I is checked in A).
<br /> D. Print the chemical name of they h za btratks substance stored in the tank and the C.A.S. . (Chemical
<br /> Abstract Servrre, I nuniber), �4z'�,-,�,,,,, 1 in A.
<br /> lll< TANK CONSTRUCTION m MARK O T EPt0 ONLY IN BOX A, SI C >
<br /> 1. Check only one item in TYPE OFSP1, 6'1'&Oi,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> if OTHER, pr, ,t in the apace;x---,0.r�d
<br /> PIPING If F i`Pv ATION
<br /> 1. Circle"A"if above ov aground�'r m:re'.f If �aa d,and circle both if applicable.
<br /> s If UNKNO10v , , I �r It hif gRg fay;.Qt ,asc ra gilded.
<br /> 3. Indicate the t. ,fr ...,tCT I NI° "vstern(s) used to comply with the monitoring requirement for the piping.
<br /> V, TANK LEAK DET i. _
<br /> 1, Indicate the'LEAK UL T E T1 1m1 sy tern(,$),_...ed tocor ply with the monitoring req firer;on!ts for the tank.
<br /> V1. INFORMATION ;res F L sn. daa sol I F.>. . T IN PLACE
<br /> I ESTIMA'I EL BATE LAST USED ma:, Tr YAR (January, 1936 or 01/88)
<br /> , _ ESTIMATED QUANTITY of l° ZARDfn 0S GLIBSTAf,JICE remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLS[., WITH INEFIT"M./Vi'.. I L.F Check"-(es'es"or."No",
<br /> TANK OWNER OR AUTHORIZED RFPf°f.ESENTA1 iVE hi'RIIfaTa SIGN AND DATE THE 'FOR S I Im
<br /> A T' D (see section 2711 (a)(1,m) CCR
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is i.rompo ed of the two digit bonny number,ber,the three digit
<br /> jurisdiction number,the six digit facility number wnd the six digit tank number. `h county and jurisdiction numbers bers are
<br /> pra etermin d and can be obtained by lling'th St t t S 'ar (916) °7-4303. The facility number must be the same as
<br /> shorn in fora"A". The tank number may be assigned by the local agency,however,this number mast be.numerical and
<br /> cannot contain an alphabet, if the local agency prefers the State Board to assign the tank number,please'166ve if blank.
<br /> IT IS TIME RESPONSIBILITY F THE LOCAL AGENCY THAT INSPECTS TS TH FACILITY TO VERIFY THE ASU_
<br /> RACY OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USF=�)NL7" INFORMATION IATIt N SC . THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. T IF PINK COPY SHOULD SF RETAINED BY THE TANK OWNER.
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