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Y £f t3 � a INSTRUCT ICONS FOR C�OMPIL I G FORM B GENERAL INSTRUCTIONS Section 2711 of Title 23, Divis€can 3, Chapter 16, California Code of Regulations and sections 25236, 25237, and 25239 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FORM "B" shall bora rxc r f ted for each tank for all NEW PERMIT S, PERMIT CHANGES, € E CO - ALS andfor any other TANK INFORMATION CHANGE, 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. please type or print clearly all requested information. 4. Use a hard paint writing instrument,you are making 3 copies. 5. Wank owners must submit a plot plan to the local agency shoeing the location of the LISTS with respect to buildings and landmarks 12711 (a)(3) CCR], 6, Tank owners rnust submit documentation shoeing compliance with.state financial responsibility require- ments to the local agency for petroleum LISTS[2711 A(l 1),CCRI, TO ' OF FORM: MARK ONLY ONE LTE 1. Turk an (X) in the box next to the item that best describes the reason the form Is being completed. 2. Indicate the COCA or Facility name where the tank is installed. i. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOW - SO SPECIFY A. Indicate owners tank ID If there is a tank number that is used by the owner to identify the tank (ex. AE7078 6), B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG), C. Indicate the year the tank was installed (ex. 1 937,. D. Indicate the tank capacity in gallons (ex.25,666 or 16,000 etc.). 61. TANK CONTENTS A. 1. IF HONpqg^OR VEHICLE FUEL, check ho 1 and complete item S S. €4` 2, If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items L1& IO, E. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). 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 in A. III. TANK CONSTRUCTION 1 - MARK ONE ITEM ONLY IN BOX A, B, C 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR ICOT LINING and CORROSION 'PROTECTION, . If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A" if above ground circle"U" if underground, and circle both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. 3. indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. 1f. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CLOSES IN PLACE 1. ESTIMATED DATE LAST USED- M ONTHNEAR (January, 1988 or 01,188) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANTO FILLED WITH INERTMATERIAL? Check 'Yes" or"No". TANK OWNER OR AUTHORIZED ED EP ESENTATI E MUST SIGN AND CRATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCF INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the 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 4.216;227-4333. 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 OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RAQY OF THE INFORMATION. THE LOCAL. AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION SOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL. AND YELLOW CONIES. THE FINK COPY SHOULD BE RETAINED BY THE TANK OWNER.