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INSTRUCTIONS FOR COMPLW_11 FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chaptel''I 6, California Code of Regulations and sections 25286, 25287,and 25289
<br /> of Chapter 6.7, Division 20, Health and Saf Code require tank owners to apply for an LIST operating pennit.
<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 INFORMATION CHANGE,
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK 111-NSPECTOR,
<br /> 3, Please type or p�rt information.
<br /> 4, Use a hard Point wri ting instnirnant,,you are,making,3 copies,
<br /> g
<br /> V, Tank owners Most SUbrllft,,a of plan to the local agency showing the location of the USTs with respect
<br /> to buildings and landmarks M711 (a)($)CCR],
<br /> 6. Tank owners must submit docunientation showing compliance with*state financial responsibility require-
<br /> ments to the local agency for petroleum UST s[2711 (a)(1 1)CCR],
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, Mark an (X) in the box next to the item that Last describes the reason the form is being completed,
<br /> 2, Indicatpthe DBA or Facility name where the tank is insta!'led,
<br /> 1. TANK DESCRIPTION - C*ISPL ETEE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners ta-111k lD 4- If there is a tank number that is used by the owner to identify the tank(ex,
<br /> B7 8911
<br /> Indicate the naln-o �,J trre l,7,,;a,`lu,,,Taf ured the tank, hor, ACME TANK MFG),
<br /> C, Indicate thye, - "H,",,oink,,�,,fas instaiied lax, 1987)
<br /> D. Indicate the tank capocity in gailons(ex,25,000 or 10,000 etc.).
<br /> 11, TANK CONTENTS
<br /> A
<br /> 1, IF MOTOR VEHICLE FUEL, check box I and complete items B&C,
<br /> 2. If not MOTOR VEHlCLE FUEL, check,the approphate box in section A and complete items B&lg.
<br /> B, Check the app roprla.c'?, box.
<br /> C, Check thetype of 1,1011CLE FUEL(if box 'l is checked in A).
<br /> D, Print the chemical riar'ne of the hazardous substance stored in the tank and the C,A.S,#, (Chemical
<br /> Abstract Service nuu,nber), if box 1 is Nor check-ed in A.
<br /> III, TANK CONSTRUCTION- MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1, Check only one item in TYPE OF SYSTEN!,TDANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. It OTHER., print In the space pr vided,
<br /> IV, PIPING INFORMIA I—ION
<br /> `I, Circle"A" if above ground ci,,,rcle"U"if underground, and circle both if applicable,
<br /> 2, If UNKNOWN i,..rcle or ff OTHER, prinfin se provided.
<br /> 3. Indicate the lJE,',A,,,KI!)ETEC,TlON systen-ols", used to comply with the monitoring requirementfor the piping.
<br /> VTANK LEAK
<br /> 1, Indicate the LEAK DETECTION ystern(s)used to comply with the monitoring requirementsfor the tank.
<br /> V1, INFORMATION ON TANK,, PERMANE,14111'71Y CLOSED IN PLACE
<br /> 1, ESTIMATED DA:rE LAST USED-MONTHIYEAR (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 MATEIRIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPFlESENIMT UVE MUST SIGN AND DATE THE FORM As INDI-
<br /> CATED (see section 2711 (a)(`l 3) CCR]
<br /> R,4,13,TRUCTION FOR THE LOCAL AGENCIES
<br /> "(he state underground fztorage,tznk,,,I,, idemiatication nurliber is��,,ornposacl of the two digit county number,thathree digit
<br /> jurisdiction number,the six digit end the six digit tank number, The county and jufisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(916)227-4303. The facility number must be the same as
<br /> shown in form"A", The tank number may lea assigned by the!renal ager cy,however,this number must be numerical and
<br /> cannot contain ark al hate' �he local agencya
<br /> prefers the St,,lt Board,to assign the tank number, please leave it blank,
<br /> IT IS THE RkSPONSIBILIT THE LOCAL AGENCY 'T,HAT INsPECTS TIMEFACIR
<br /> ly, I , UTY TO ERI
<br /> VFY THE -
<br /> ACCIJANFOR
<br /> CY OF THE IMATION, T
<br /> HE LOCAL. AGENCY IS RESPONSIBLE 'THE COMPLETION OF THE
<br /> "LOCAL AGENCY USIE 0LI YI' !NFORMATION BOX, THE 'LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE P!NK COPY SHOULD BE RETAINED BY THE TANK OWNER,
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