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INSTRUCTIONS FOR COMPLETING FORM "B" <br />GENERAL INSTRUCTIONS <br />Section 2711cfTitle 23.Division 3,Chapter 1G,California Code ofRegulations and sections 2520G.25287,and 25288 <br />of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. <br />1� One FORK�"B"shall becompleted f htankfora||NEVVPERK4|TS.PERK4|T{�HANGES.REk4DV- <br />` ALS and/or any otherTANK INFORMATION CHANGE. <br />2. This form should becompleted byeitheth PERM|TAPPL(CANT or the LOCAL AGENCY UNDER- <br />GROUND <br />3. Please type nrprint clearly all requested information. _ <br />4. Use ahard point writing instrument, you are making 3copies. <br />5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect <br />tobuildings and landmarks [2711 (a)(8)CCRl <br />G� Tank owners must submit documentation showing compliance with state financial responsibility require- <br />ments to the -local agency for petroleum USTs (2711 (a)(1 1) CCR]. <br />TOP OF FORM: MARK ONLY ONE ITEM <br />1. Mark an(X)inthe box next td the <br />item that best describes the reason the form inbeing completed. <br />2. Indicate the DBA orFacility name where the tank- \s''inataUod. <br />TANK DESCRIPTION -COMPLETEALL ITEMS '|FUNKNOWN -8DSPECIFY <br />A. Indicate owners tank|O#-Kthere is a tank number that is used by the owner to identify the tank (ex. <br />B. Indicate the name of the companythat manufactured the tank (emACME TANK MFG). <br />C. Indicate the year the tank was installed (e«.1QG7). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />U. TANK CONTENTS ^ ` <br />A. 1. |FMOTOR VEHICLE FUEL, check box 1and complete items B & C. <br />2. If not MOTOR VEHICLE FUEL, check the appropriate box insection Aand complete items B&D. <br />B. Check the appropriate box. <br />C. Check the type ofMOTOR VEHICLE FUEL (if box 1 ischecked h?A). <br />D. Print the chemical name ofthe hazardous substance stth <br />orodinetsnkandtheC.A.G.#. (Chemical <br />Abstract Service number).ifbox 1 iaNOT checked inA. <br />Ui TANK CONSTRUCTION'- MARK ONE ITEM ONLY IN BOX A, B. C & D <br />1, Check only one item inTYPE [}FSYSTEM, TANK MATER|AL.!NTER|ORL|N/N��and CORROSION <br />_ PROTECTION. --- <br />2.- KOTHER, print inthe space provided. ` <br />|V. PIPING INFORMATION <br />1, Circle "A" ifabove ground cinJe"U"ifunderground, and circle both ifapplicable. <br />2. |fUNKNOWN circle; orifOTHER, print inspace provided. _ <br />3. Indicate tite LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DETECTION <br />1� Indicate the used to - with the mr-nitohnorequirements for the tank. <br />' <br />Vi INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED -lWONTH/YEA rK1088or81/887- <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). .- <br />3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yea"or"No". <br />TANK OWNER DRAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- <br />CATED (see section 2711 (a)MG\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 numbeF, the six digit facility number and the six digit tank number. The county and jurisdiction 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;�.rip,"A". The tank nunte,eo.* be assigned by the local agency, however, this number must be numerical and <br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFYTHE ACCU' <br />iN+UHxH3T)ON. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE <br />^LbCA, AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND <br />YELLOW COPIES. THE PINK U���/ SHOULD BE RETAINED BY THE TANI���� NER. <br />���� <br />~� �� <br />