|
INSTRUCTIONS FOR COMPLE10 FOS "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25266,25267, and 26269
<br /> f Chapter 6.7,Division 20, Health and Safety Code require tank owners to apply for an LUST operating permit.
<br /> 1, One FORM"B"shall be completed for each tank for all NEW PERMITS, PERMIT"CHANGES, REMOV-
<br /> ALS
<br /> F .oALS and/or any ether TANK INFORMATION CHANGE.
<br /> . This forth should be completed by either the PERMIT APPLICANT or the LOCA,AGENCY UNDER-
<br /> GROUND
<br /> N FPmPC L TANK INSPECTOR,
<br /> . Please type or print clearly all requested information.
<br /> Use a lard point writing instrument,you are making 3 copies,
<br /> s. Tank owners roust submit a plot plan to the local agency showing the location of the STs with respect
<br /> to buildings and landmarks[2711 (a)(8)CCRI,
<br /> 6. _ Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments
<br /> eq ire-ment to the local agency for petroleum LISTS 27°I (a)(1 R].
<br /> TOP OF FORM: MARK ONLY ONE ITE
<br /> 1. Mark in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the IPPA or Facility name where the tank is installed.
<br /> . TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN m SCS 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 /> AP7Q7P .
<br /> , Indicate the name of the company that manufactured the tank (ex,ACMETANK 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 /> it. 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 fif box I is checked in A}m
<br /> D. Print the chemical verse of the hazardous substance stance shred in the teak and the C.A.S.ft, (Chemical
<br /> Abstract Service number), i box 1 is NOT checked in A.
<br /> III, TANK CONSTRUCTION -MARK ONE ITEM ONLY IN PDX A$ B, C & D
<br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION.
<br /> 2. if OTHER, print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> N
<br /> `l. Circle"A"if above ground circle"U"if underground, and circle beth if applicable.
<br /> If UNKNOWN circle;or if OTHER, print in apace provided,
<br /> , Indicate the LEAD,DETECTION system(s) used to comply with the monitoring requirement for the piping'-
<br /> V, TANK LEAD DETECTION
<br /> IST
<br /> 1. Indicate the LEAD DETECTION systems used to comply with the;monitoring requirements for the tank.
<br /> VL INFORMATION L N TANK PERMANENTLY LSE IN PLACE
<br /> 1. ESTIMATED DATE LAST USED - NTH/YEAR(January, 1286 or 01/68
<br /> 2. ESTIMATED QUANTITY 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 BLEST SIGN AND DATE THE FORM AS INDI-
<br /> CATED (see section 2711 (a)(13) Ff
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> 1-he Mate underground storage tank identification numb er 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 roust be the same as
<br /> shown in ferry"A", The tank number may be assigned by the local agency,however,this number roost be numerical and
<br /> cannot o to r`I, ' 1p abet. If the l nc prefers-the State Board to assign the tank number, Tease leave it blank.
<br /> IT I6 THE P I LIT F THE4L CAL A FW T I IAS Ia F T THE FACILITY I"£ 1 ISP A I®
<br /> .PAY F .l FGf MATIOII` TPF D A AOFN Y` I PLSPO� I E FBF THE OMPLETIL OF THE
<br /> "..� NCY USE ONLY" INFORMATION PG . THE LOCAL AGE GHOUL PLT AIN THF ORIGINAL AND
<br /> y FL' �IF6, THE PINK.COPY SHOULD BE RETAINED BY THE TANK OWNER,
<br />
|