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INSTRUCTIONS FOR COMP LOING FORM "B"
<br /> GENERAL INSTRUCT IONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit,
<br /> 1. One FORM "B" shall be corner "ed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any o"Ah- TANK INFORMATION CHANGE,
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> 3, 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 buildings and landirnarks [2711 (a)(8)CCR],
<br /> 6, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs [27 11 (a){11) CCR].
<br /> TOP OF FORMs MARK ONLY ONE ITEM
<br /> 1, 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 /> 1. 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 /> AB'170789,).
<br /> F. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG).
<br /> C, Indicate the year the tank was installed (ex, 1987),
<br /> D, Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc,).
<br /> If. TANK CONTENTS
<br /> A, 1, IF MOTOR VEHICLE FUEL, check box 1 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. ICheck 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 /> 3, Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> VTANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION systern(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 - MONTHNEAR (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3. 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 /> DATED [see section 2711 (a)(13) CC.R]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county 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. The facility number must be the same as
<br /> shown in form "A". The tank number may be assigned by the local agency, however,this number must be numerical and
<br /> cannot containaroalphabet, If tine l6cagency prefers the State Board to assign the tank number, please leave it blank.
<br /> IT IS THE RESPONSIBILITY 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 /> ,"LOCAL 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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