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INSTRUCTIONS FOR OMR INCA FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 27 f 1 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 Safely Code require tank owners to apply for an LIST operating permit.
<br /> I One FORM "B" sliali be cc.,rnpketed for each tank for all NEW PERIMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other 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 reques'ted information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> 5. Tank owners must submit a plot plan to-tfie local agency showing the location of the USTs with respect
<br /> to buildings and landmarks (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 [2711 (a)(11) CCRJ.
<br /> TOP OF FORM- 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 /> 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. 1987),
<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 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 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 /> lv. 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 /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1 ESTIMATED DATE LAST USED ar MONTH/YEAR (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 /> CATED [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 two digit county number, the three digit
<br /> jurisdiction number, the six digit facility number and the sig,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 contain an alphabet. If the I agency 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. TiE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> k, ,,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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