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INSTRUCTIONS ION OMPLE 1 O "B"
<br />GENERAL INSTRUCTIONS
<br />RUCTIONS
<br />Section 2711 of i itie 33, Division 3, Chapter 16, Cale4orni;a Code of Regulations and sections 2528 S; 3,3287 , and 23239
<br />of Chapter 6, 7, Division 20, a lea€th and Safety C''ode require tank owners to apply for an UST operating pcsarn-lit,
<br />I , One FORM "B" shall be completed to, each tank for all NEW PERMITS, S, PE Mi T CHANGES, REMOV-
<br />ALS andfor any tether TANK INFORMATION CHANGE,
<br />2, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br />GROUND
<br />NCF -
<br />GROU `D TANK INSPECTOR,
<br />3. 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 roust submit a plot plan to the local agency shoving the location of the USTs with respect
<br />to buildings and landmarks [2711 (a)(3) CCR).
<br />3. Tank owners roust submit documentation showing compliance with stag financial responsibility require-
<br />ments to the local agency for petroleum UST [2711 (a)(11) CCR].
<br />TCT OF FORM: MARK ONLY ONE ITEM
<br />;. Mark an () in the box next to the item that feast describes the reason the form Is being completed.
<br />2. Indicate the BSA or Facility name where the tank it Installed.
<br />TANK DESCRIPTION IPTION - COMPLETE ALL. ITEMS - IF UNKNOWN - SCS SPECIFY
<br />A. indicate owners tank IS # m If there is a tank number that is used by the owner to identify the tank (ex.
<br />AS70709),
<br />Indicate the name of the company that manufactured the tank (ex, ACME TANK MFG),
<br />C, Indicate the year the tank was installed (ex, 1937).
<br />DIndicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.).
<br />Ila TANK CONTENTS
<br />A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B & C,
<br />. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D.
<br />S. Check the appropriate boat.
<br />C. Check the type of MOTOR VEHICLE FUEL (if box. 1 is checked in A).
<br />} 'rint the chemical name of the hazardous substance stored in the tank and the C.A.S,#. (Chemical
<br />Abstract Service number), if boat 1 is NOT checked in A,
<br />Ill. TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, S, C & D
<br />1, Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION
<br />N
<br />PROTECTION,
<br />2. If OTHER, print in the space provided.
<br />lvt ICING INFORMATION
<br />1. Circle "A" if above ground circle "U" if underground, and circle both if applicable,
<br />2. If UNKNOWN circle; or if OTHER, print in space provided.
<br />. Indicate the LEAD DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br />Vt TANK LEAK DETECTION
<br />1. Indicate the LEAD DETECTION system(s) used to comply with the monitoring requirements for the tank.
<br />V1. INFORMATION ON TANK PERMANENTLY CLOSED IN FLAG
<br />1. ESTIMATED GATE LAST USED - MCN "H,YFAR (January, 1983 or 01/88)
<br />2. ESTIMATED QUANTITY f HAZARDOUS ARL OUS SUBSTANCE remaining In the tank (in Gallons).
<br />3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No",
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND LATE THE FORM AS INDI-
<br />CATED
<br />NDICAT D (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 (915) 227-4,301 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 contairi art alphabet.- If the local agency prefers the State Board to assign the tank number, please leave it blank.
<br />IT IS THE E rONSISILITY''OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br />RACY OF THE INFORMATION, THE LOCAL AGENCYIS E PFONSILE FDR THE C ?MPLETION Gip` THE
<br />"LOCAL AGENCY USE ONLY" INFORMATION SOX. T £( � •L 3CAL AGENCY SHOULD RETAIN THE ORIGINAL AN
<br />YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED 3Y THE TANKOWNER, :
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