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INSTRUCTIONS FOR COMPLE10 FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Codeof Regulations and sections 25266, 25267,and 252269
<br /> of Chapter 6.7,Division 20, Health and Safety Grade require tank owners to apply for an LIST operating permit.
<br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHIv ,
<br /> .,.,.$ 2. This fora should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> 5. Please type or print clearly all requested information.
<br /> Use a hard point writing instrument,you are.making 5 copies.
<br /> 5, Tank owners must submit a plot plan to the local regency showing the location of the LIST"s with respect
<br /> to buildings and landmarks(2711 ( )( )CCR),
<br /> 6, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum LISTS[2711 (a)(11) GCR].
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, Mark an (X) in the fox next to the item that bast describes the reason the form is being completed,
<br /> . Indicate the DBA or Facility name where the tank is installed,
<br /> . TAMS DESCRIPTION - COMPLETE .ALL ITEMS - IF UN - SO SPECIFY
<br /> Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex,
<br /> 7762).
<br /> E, Indicate the name of the compan that manufactured the tank (e , CME 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 o etc.),
<br /> It. TANK ITEI TS
<br /> A. 1._IF MOTOR VEHICLE FUEL,check box °I and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL,cheek the appropriate box in section A and complete items IS&D,
<br /> , Check the appropriate baa ,
<br /> C. Check the type of MC)TOR VEHICLEFUEL(if bond 1 is checked:d in ),
<br /> D, Print the chemical name of the hazardous substance stored in the tank and the . , , , (Chemical
<br /> Abstract Service number),if box 1 is NOT checked in A,
<br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B,
<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 /> TIO
<br /> 1, Circle"A"if above ground circle"U"if underground,and circle both if applicable,
<br /> , If UNKNOWN circler; or if OTHER, print in space provided,
<br /> Indicate the LEAK DETECTION ECTION .ystemts)used to comply with the monitoring requirement for the piping.
<br /> V, TANK LEAK DETECTION
<br /> t: Indicate the LEAK DETECTION system(s)used to comply with the moniton.ng requirements for the tank,
<br /> tyls INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR)January, 1266 or 01/88)
<br /> 2, ESTIMATED QU TIT of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons),
<br /> 2, 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
<br /> I-
<br /> C TE (see section 2711 (a)(1 ) CCR)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> `he state underground storage tank identification number is cornporT.ed 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)227-4203, The facility number must be the same as
<br /> cannot contain tri alphabet. If the 1 &,racy prefers the State card to assign the tank number, please leave it I and
<br /> shun in form . The tank number may be assigned b the local enc ,however,this number rust be numerical
<br /> blank.
<br /> IT (6 THE 8TtL k � '� THAT INSPECTS THE FACILITY TO VERIFYTHE ACCU.
<br /> :11A Y OF THE'Tt4FbRIMAYION, THE L i5 'AbE ° IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> f `VSE OILY" INFORMATION SOX, THE FOCAL AGENCY SHOULD RETAIL THE ORIGINAL AND
<br /> EL
<br /> YL pit&. THE PINK €OP SHOULD BE RETAINED BY THE TANK .S E T,
<br />
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