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INSTRUCTIONS FOR COMPLOG, 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 LIST operating permit.
<br /> 1. One FORM "B"shall be completed for each tank for all NEWPERMITS, PERMITCHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> aw This form should be completed by either the-PERMIT APPLICANTor the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> 1 Please 1-ypb,,,,,r pdnt clearly all requested inforniwilon.
<br /> 4, Use a hard point wdhnyl in,,Apiment,you are making 3 copies,,
<br /> 5, 'rank owriers must submit a plot plan to the lc ,;al agency showing the location of the US Ts with respect
<br /> to buildingsan:d 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 Ii[2711 (a)(1 1)CCRJ,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 4
<br /> I, Mark an (X) in the box next to the item that best describes the reason t!3,ericirm is being completed,
<br /> 2. Indicate the DNA or Facility name where the tank is insWred,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEMS iF-'UNKNOWN - SO SPECIFY
<br /> Ax Indicate owners-tank ID If- If there isian
<br /> at
<br /> AB70789), k number that is used by the owner to identify the tank(ex.
<br /> B, Indicate the nann,.,,, 'the tank(ex,ACME TANK MFG),
<br /> CIndicate the ye,,u 0-* !ankivas (Q-x, I 987i_
<br /> D. Indicate the tank capacity in gallons lox,25,000 or 10,000 etc,'),
<br /> AN CONTENTS
<br /> A
<br /> 1, IF MOT- R VEHICLE FUEL, check box 1 and complete items B&Ca
<br /> Z If not MOTOT1 VEHICLE FUEL, check the appropriate box in section A and complete items B&D.
<br /> B, Check the appropriate box,
<br /> C, Check t1he type of VEHICLE FLIEL..(if box checked In A)_
<br /> D, Print the chemical rrcrrns of the hazardous substance stored in the,fank and the C.A,S.#, (Chemical
<br /> Abstract Service riumber", if box "I is NC;T checked in A,
<br /> III, TANK CONSTRUCTION -MARK ONE l'!'EM ONLY IN BOX A, B, C & D
<br /> 1 Check only one"Iternin T YPE OF sYsTEM,TAN K MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2, If OTHER, print in the space pre,'-wiried,
<br /> ivu PIPING INFO RMA-1`10N
<br /> 1, Circle"A" 'if aboveground acl '113'if ures ereroumd, and circle both if applicable.
<br /> 2, If UNKNOWN or iii`,_ UiEprint rn spac,,e provided.
<br /> 3, Indicate the LEAK DCfECT!01smern(s) ,used-o comply with the monitoring requirementTor the piping.
<br /> VTANK LEAK DE."'Eg",
<br /> 1 Indicate the LEAK DETECTION system(s% used to comply with the monitoring requirements for the tank.
<br /> Vrx INFORMATION ON! TANK PERIWANENTLY CLOSED IN PLACE
<br /> 11 l'
<br /> I ESTIM,"V"ED DATE LASTLISED- MCN',1-,H/YEAF�,, (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTiTY of HAZA13DOUS SUBSTANCE remaining in the tank in Gallons),
<br /> 3, WASTANI<FILLED VVITH INEPTMATERIAL9 Check"Yes'or"No".
<br /> OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED (seesection 2711 a)113) CCRJ
<br /> lNSTRUCTION FOR THE LOCAL AGENCIES
<br /> i,e SIMM Underground storage tonk identification number is corlr9osed ofthe two digit county number,the three digit
<br /> jultsdiction number,the six digit faciliell number and the six digit tank number, The county and jurisdiction numbers are
<br /> predetermined and can be obtained blicalling the'State,Board(9161227-4303, The facility number must be the same as
<br /> shown in form "A", The tank
<br /> numberniay be assigned by the local agency,however,this number must be numerical and
<br /> cannot con,ain an alphabet, If the ioctil agency prefers Irre Stale Board to assign the tank number, please leave it blank.
<br /> IT IS THERESPONJIB!UTY OF THE LOCAL, AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORNIATION. THE LOCAL AGENCY IS RESPONSIBLE FOS 'THE- COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY' lNF(,`X`irsATION BOX, TIHE LOCAL AGENCY SHOULD RETAIN THE OPIG NAL AND
<br /> YELLOW COPIES. THE PlNK COPY SII ,,+. BE RETAINED BY 7HE TANK OWNER,
<br />
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