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INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<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 UST operating perrnit,
<br /> 1 One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/o�any other TANK INFORMATION CHANGE,
<br /> 2, This form should be cornpleted by either the PERMIT AFIPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> 1 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 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 [27 11 (a)(11) CtCRJ,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next to tie 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 - IFUNKNOWN - 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 /> AS 70789).
<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 /> ll. TANK CONTENTS
<br /> A. 1, IF MOTOR VEHICLE FUEL, check box 1 and complete items IS & C.
<br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&U.
<br /> B, Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in, j.
<br /> T. Print the chemical narne of the hazardous substance stored in the-tank and the C.A.SA. (Chemical
<br /> Abstract Service number), it box I is NOT checked in A.
<br /> III, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> I 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 /> 1. Circle"A" if above ground circle"U" if underground, and circle both if applicable,
<br /> 2, If UCWN circle, or if OTHER, print in space provided,
<br /> 1 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 - MONTHYEAR (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 cumber and the six digit tank 6bmbe7r. The'cotinty and jurisdiction numbers are
<br /> pcadi:jermined and can be obtained by calling the State Board (916)22744803.-The facility number must be the same as
<br /> shown in forryi"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 local 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, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INE MATION BOX. THE LOCAL AGENCY SR W RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES, THE Pit SHOULD BE RETAIED BY THE TANK ER,
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