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� � �IO^ ^B^|NSTRUCT|ONS FOR QOKPL | K GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division 3. Chapter 1G. California Code ofRegulations and sections 2S28G. 25287. and 2528Q ofChapter G7. Division 20. Health and Safety Code require tank owners 0oapply for an LIST operating permit. 1. One FORM "B" shall becompleted for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should becompleted byoitherthePERK8|TAPPL|CANTorthoLOCALAGENCYUNDER- GRDUNOTANK |NSPECTOR. 3, Please type orprint clearly all requested information. 4. Use ahard point writing instrument, you are making 3copies. 5. Tank owners must submit e plot plantotha |oca| agenoyahmmingMhe|000donoftheUGTnvvithrempeot to buildings and landmarks (a)(8)CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- mentstutha|oca|agencyforpotno|eumUSTo[2711 (a)(11)CCR}. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark anp0inthe box next to the item that best describes the reason the form iebeing completed. 2. Indicate the DBA orFacility name where the tank h;installed. |. TANK DESCRIPTION - COMPLETE ALL |TEK88 ' IF UNKNOWN - 8C) SPECIFY A. Indicate owners tank |D #' |fthere iaotank number that iaused bythe owner toidenUfvthetonk �ex' AB7O78Q� ' � B. Indicate the name ofthe company that manufactured the tank(ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1S87). D. Indicate the tank capacity ingallons (ex. 26.00Oor1U.UUOetc.). |i TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and complete items B&C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items 6&D. B. Check the appropriate box, C. Check the type ofMOTOR VEHICLE FUEL(if box 1 inchecked inA). D� Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked inA. ||i TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C Q D 1. Check only one item inTYPE DFSYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER, print in the apace provided. |V. PIPING INFORMATION 1. Circle"A" if above ground circle"U" if undargnound, and circle both if applicable. 2. If UNKNOWN circle; or if DTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. � V|. }NF{}RKXAT|{}N ON TANK PERMANENTLY CLOSED IN PLACE � 1. ESTIMATED DATE LAST USED- K4ONTH/YEAR nuory. 1S8DorO1/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yea"or"No". - TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATE O (see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification numb is composedcfthe two digit county number,the three digit jurisdiction number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)227-4303. The facility number must be the same as shown in form"A". The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY UFTHE LOCAL AGENCY THAT INSPECTS THE FACILITY TOVERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USEONLY'' INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANKNER. 0� is