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INSTRUCTIONS FOR COMPLETING FCS "B"
<br /> GENERAL INSTRUCTIONS
<br /> IONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286,25237, and 25289
<br /> of Chapter E.7, Division 20, Health and Safety Code require tank owners to apply for an UST 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 I FORNIATION CHANGE,
<br /> 2. This form should be completed by either the PERMIT"APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TAM{INSPECTOR,
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard paint waiting instrument, you are making 3 copies,
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the LISTS with respect
<br /> to buildings and landmarks(2711 (a)(8) CCR].
<br /> Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum U STs[2711 (a)(11) CCR],
<br /> COP OF FORM: DARK ONLY ONE STEM
<br /> 1. Lark an i ) in the box next to the item that best desribes the reason the form is being completed,
<br /> 2. indicate the L3EA or Facility name where the tank is installed.
<br /> I. TANK DESCRIPTION - COMPLETE ALL ITEMS m IF UNKNOWN MOWN - SO SPECIFY
<br /> A. Indicate owners tank I m if there is a tank number that is used by the owner to identify the tank(ex.
<br /> A7375g).
<br /> B, Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG),
<br /> Indicate the year the tank was installed (ex. 1957).
<br /> T. 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_L &C,
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items E&D.
<br /> E. Check the appropriate box.
<br /> S. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in
<br /> D� Print the chemical name of the hazardous substance stored in the lank and the C .A.S. . (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> III, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOXA, P- C & D
<br /> I Check only one item in TYPE OF Y TEM, ANA 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"it 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 LEAD DETECTION
<br /> TIO
<br /> 1. Indicate the LEAK DETECTION systems used to comply with the r ohtoring requirements-for the tank.
<br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE LASw; USED m ONTHiYEA (January, 1988 or 01785)
<br /> . ESTIMATED QUANTITY TIT of HAZARDOUS ARDOUS SUBSTAI C'E 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)(13) C. R
<br /> INSTRUCTION FO 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 juriiscliction numbers are
<br /> predetermined and can be obtained by calling the State Board(915)22�'-430S The facility number must be the same as
<br /> shown in frarnt"A", The tank nLimber-mAy be assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet: If the local_ag�ncy prefers the State ward to assign the tank number, please leave it blank.
<br /> IT 1S THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY
<br /> U U-
<br /> RA Y OF THE INFORMATION. THE LOCAL AGENCY 1S RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USEONLY" IM*SHOULD
<br /> ATION C . THE LO AL GENC Y I ETAIN TIDE l lr�a-`INAL ANYELLOW C OPIEs. THE PitBE r ETAINE a FY THE TAIL€ EST.
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