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INSTRUCTIONS FOR COMPLE* 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, PERiMIT CHANCES, REMOV-
<br /> ALS and/(.,,r any other TANK INFORMATIONCHANGE,
<br /> 2, This form should be completed by either the PERMIT APPLICANT or the 'LOCAL AGENCY UNDER-
<br /> GROUND TANIK INSPECTOR,
<br /> 3, Please type pi�Mt clearly all requested
<br /> 4Use a hard point writing instrument,you are making 3 copies,,,,
<br /> d. Tank owners must submit a plot plan to the local agency showing the location of the ft with respect
<br /> to buildings and landmarks(2711 (a)(8) CCR],
<br /> 6, Tank owners-must submit documentation showing compliance w'ith state financial responsibility requ
<br /> mire-
<br /> ents to the local agency for petroleum UST [2711 (a)(1 1)CCRJ,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> R. Mark an (5Z),in the box next to the item thin,best descbbes the reason the form is being completed,
<br /> 2, Indicate the bBA or Facility name where the tank is,instaffied,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ,ITEMS - IF UNKNOVkIN - SO SPECIFY
<br /> A. Indicate owners tank ID#-If there is a tank number that is used by the ownerto identify the tank(ex.
<br /> AB70789),
<br /> B, Indicate I'fie name of the company that rnanufacbured tani'%,fex,ACME K M
<br /> TANFG),
<br /> G., Indicate the year thetank was installed 11ex, 1987),
<br /> Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc,).
<br /> If. TANK CONTENTS
<br /> A, 1, IF MOTOR VEHICLE FUEL,check box I and complete items B&C,
<br /> 2. if not MOTOR VEHICLE FUEL,one,e,r Ithe appropriate box in section A and complete items B&D,
<br /> B� Check thesppropriiate box
<br /> 'he type of �,C,)TIOR VEHICL -(
<br /> E FJIEL '(�q box checked�An A),
<br /> C. Checkt
<br /> D, Print the chemical name of the haoar-do,,us stoi,-eci in the tankand the C.A,S,#. (Chemical
<br /> Abstract Service number),if box" is N(,,'r`l`che�cked in A,
<br /> III, TANK CONSTRUCTION- MIARK 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 /> lvPIPING INFORMATION
<br /> 1, Circle"A" it Above ground circle"U"if unde,gnx,,,un,,d, and circle both if applicable.
<br /> 2, If UNKNOWN circ.leTol, r OTHER, print in space
<br /> 3, Indicate tlhc,�,LEE,`,�,%K Dfa�,77'ECTIOf,l sys'NA+n"'t"", 'Comnply will,the monitoring requirwrnant lor the piping.
<br /> VTANK LEAK DETECTION
<br /> 1, Indicate the LEAK DETECTION sybtem(s)uGRj to comply with the monitoring requirementa fur the tank.
<br /> VI, INFORMATION ON AN PERMANENTLY ('31LOSED IN PLACE
<br /> I ESTIMATED DATE LAST USEONTHNEAR kJ uar"ye t 988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUSSUBSTA,NCE remaining in the tank.,(in Gallons),
<br /> 3, WAS TANK FILLED WITH INERT MATERIMLY Check'Yes,"or "No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTA11VE NIUST SIGN AND DATE THE FORM AS IND]-
<br /> CATED [see section 2711 ta!"!3) OCR)
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<br /> UN SRUC TION FOR 'I"HE LOCAL AGENCa-IES
<br /> he sta,
<br /> ,a underground storage tank identification number is composed of the Mo digit courify nurnber,the three digit
<br /> jurisdictiom number,the six digit facility number and the six digit I,to r*- umber, The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Bard qct Cpl 22-17-4303, The facility number Met 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 local agency prefers the SumeBoard to assign the tank,number,please leave it blank.
<br /> ,IT IS THE FIESPONSIBILITY OF THE LOC I AGENCY 11"HAT INSPECTS THE FACILITY TO Imo ? ACCU-
<br /> AL
<br /> RACY OF THE INFORtAATl0N, THE LOCAL AGENCY IS RESPONSIELE FOR THE COMPLETION OF THE
<br /> 'LOCAL AGENCY USIEEOrll,,Y�' INFORMATION BOX, THE_ LOCAL AGENCY '3HOULD F`IETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PiNK COPY SHOULD BE RET
<br /> ,_ BY THE 1'ANK OWNEI'L
<br /> A,
<br />
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