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AWL
<br /> INSTRUCTIONS FOR COMPIPLING FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 67, Division 20, Health and Safet,,j Code require tank owners to apply for an LIST operating permit,
<br /> 1 One FORM "Bbe for each tank Or all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS arid/o,any other'IANK INFORMIAT l0f,4 CHANGE,
<br /> 2, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> & Please type or print clearly all requested information.
<br /> 4� Use a hard point writing instrument, you are making 3 copies,
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect
<br /> to b0clinas and landmarks 12711 (a)(8)CCR].
<br /> 6, Tank owners'must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency to,,,petroleum USTs [27,11 (a)(1 1) CCRJ,'
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> I Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> L TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex.
<br /> AB70789).
<br /> B, Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG),
<br /> C. Indicate the year the tank was installed(ex. 19887),
<br /> D. Indicate the tank capacity in gallons (ex, 25,000 or 10,000 etc,),
<br /> il. TANK CONTENTS
<br /> A. 1, IF MOTOR VEHICLE FUEL, check box I and complete items B& C,
<br /> 2, If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B& 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 and the C.A.S,#, (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> Ill. TANK CONSTRUCTION-_ MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. Check only one item in TYPE OF SYSTEM,TANK,MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2, if OTHER, print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> 1. Circle"A" if above ground circle "U" if underground, and circle both if applicable,
<br /> 2. If UNKNOWN circle; or if OTHER, print in space provided,
<br /> 1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAS DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1 ESTIMATED DATE LAST USED LNTHNEAR (January, 1988 or 01/8£0
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 1 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 /> GATED (see section 2711 (a)(1 3) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank Identification number,is composed of the Nvo digit county I number, the three digit
<br /> jurisdiction number, the six digit facility number and the six digit tank,number, The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board (916)227-4303. 'It-he facility number must be the same as
<br /> shown in form "A,", The tank number rn,ay,be assigned by the local agency, however,this number must be numerical and
<br /> cannot cont din an alphabet. If the li5ctal;agerLcy prefers the State Board to assign the tank number, please leave it blank,
<br /> IT IS THE -RB SPQR SIBILITY' OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> ,`1_60AL AGENCY USE ONLY` INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER,
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