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7W
<br /> INSTRUCTIONS FOR COMPLW- FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 11 6, 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 permit.
<br /> I One FORM "B"shall be completed for each tank for all NEW PERMITS, PERM I"I"CHANGES, REMOV.,
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 2. This form should be ccn�ipieted by either the PERM IT APPLICANT or the LOCAL AGENCY UNDER-
<br /> IS R 0 U N D T A N K I Ni S P r1-_,,'0'r 0 Pl,
<br /> 3, Please type e I,
<br /> 4, Use a hard Inst rarnerit, youare.nnaking 3 copies,
<br /> 5 -
<br /> > Tank owners must subrnit a piat plan to the local agency showing the location ol,"the USTs with respect
<br /> to buildings and landrnarks I27 11 (a)(8) CCRI,
<br /> 6. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the,-,tocal 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 rrext to tho itern that best describes the reason the form is being completed,
<br /> 2, Indicate-'the- DBA or Facility nwrne where the tank is instafled,
<br /> I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. indicate owners tank iD tt If her tank num-merthat-is used by the owner to identittr the tank(ex.
<br /> AB70789"
<br /> P
<br /> B, indicate the th'al,rnanufaare IsUneed th- ounk (ex,ACME TANK KIPS),
<br /> C, Indicate the yeain, til,'
<br /> r e I nk w,-ia installed (rx, 1987",
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 ertc,)
<br /> If. TANK CONTENTS
<br /> A, 1. IF MOTOR VEHICLE FUEL, box I andcomplete items B&C.
<br /> 2, If notMOTOR'%`EH,,,CLE FUU"'11" "';'l-vocIrthe'appropriate box in section A and complete iterns IS&D,
<br /> 6, Check the app.op
<br /> C, Check the r pe of 6,41CY1'OR, i43il., 1' is checked in A),
<br /> D, Print the chernicai narrit,,i of lov"r h;az�.,arcicAxsubstance, sto,,�red in the tank and the C,A.S,#, (Chemical
<br /> Abstract Servici,� nurrnber), it ix,-,x i in A,
<br /> III, TANK CONSTRUCTION - MARK ONE IT 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-1,prinll in the space,prnMded,
<br /> v, PIPING 11NIFORN4,11ATION
<br /> i. Circle"A" ff'-above grou.nd cc,�Fckt`LP if midargreund,and circle both if applicable.
<br /> if UNKNOV�Vl%i circ:fe, V�0 Tf-KEJR win,"in cmvided-
<br /> 3� Indicate Hh-,_,� cornol vvit1h'he, monitor'
<br /> �, ing requirement for the piping.
<br /> V. TANK 'LEAK
<br /> N
<br /> 'ETEGI-ION system-n(s)used to comply with the monitoring requirements for the tank,
<br /> Indicate the LEAD
<br /> K
<br /> VI, INFORMATION ON TANK 0LOSED IN PLACE
<br /> 1, ESTIMATED DATE, LAST IJS11,,D blOINTIH/YEAR (January, 1988 or 01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOLIS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3, WAS TANK FILLED WITH INER"I"I'VIATERIAL? Check"Yes'or"No".
<br /> TANK OWNER OR AUTHORVED r3EPRESEN'I'ATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED (see section 2711 (a)�'l 3) CCR]
<br /> N FOR THE LOCAL AGENCIES
<br /> ,,NISTRUCTI
<br /> e state underground nUflrrbrsir l,,s composed ofthe two digit county number,thethree digit
<br /> xisdiction number,the six digit facilit,,t,nurnber and th'is six dilit tank number, The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling 1l'ie State Board M16)2207-4303, The facility number must be the same as
<br /> shown in form "A". The tank number rsay be assionted by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet, iffthe ic,)c-aI agency prefers the State Board to assign the tank number,please',save it blank,
<br /> � r ,F THE LOQAI AGENCY THAI,' 'INSPECT S THE FAC L--Y TO VER THE ACCIJ-
<br /> 1T IS THE RESPONS01 11 y 0 L I
<br /> I IT IFY
<br /> R A C Y C,I F TIME I N FFOROM,A1-10 N TH' LOCAL AGENCY 'IS RESPONSIBLE FOW THE COMPLET!ON OF THE
<br /> "LOCAL AGENCY USLE OW,Y�' 1Nii"%,1R1,?`iATlON BOX, THE 1_0CAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE FINK GX)PY &-11,01Y-D BE RE`€AINED, BV THE T;ikNK OWNER,
<br />
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