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INSTRUCTIONS FOR COMPLETING 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 67, 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 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 INSPECTOR,
<br />1 Please type or print clearly all requested information,
<br />4. Use a hard point writing instrument, you are making 3 copies,
<br />5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect
<br />to buildings and 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 USTs [2711 (a)(11) CCR],
<br />TOP OF FORM, MARK ONLY ONE ITEM
<br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />2. Indicate the DBA or Facility name where the tank is'installed,
<br />L TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br />A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex.
<br />AB70789).
<br />B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG).
<br />C. Indicate the year the tank was installed (ex, 1987).
<br />D. Indicate the tank capacity in gallons (ex, 25,000 or 10,000 etc,).
<br />IL TANK CONTENTS
<br />A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B & C.
<br />2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D.
<br />B. Check the appropriate box.
<br />C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A).
<br />D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical
<br />Abstract Service number), if box 1 is NOT checked 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 SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION
<br />PROTECTION,
<br />2, If OTHER, print in the space provided.
<br />iv. PIPING INFORMATION
<br />1, Circle "A" if above ground circle "Ll" if underground, and circle both if applicable,
<br />2. If UNKNOWN circle; or if OTHER, print in space provided.
<br />1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LEAK DETECTION
<br />1 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank.
<br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br />1, ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01 /88)
<br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br />1 WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No".
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br />CATED [see section 2711 (a)(13) 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 number, 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 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 State Board to assign the tank number, please leave it blank.
<br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br />RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br />,,LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br />YELLOW COPIES, THE PINK COY SHOULD BE RETAINED BY THE TANK OWNER.
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