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<br /> INSTRUCTIONS NS FOR COMPLETING FORM f'B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23; Division S, Chapter 15,California Code of Regulations and sections 25285, 25257, and 25289
<br /> of Ch ter 6.7, Division SP, 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 CHANGBS,,REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE,
<br /> ;. This form should be completed by either the PERMIT APPLICANT"or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPEC=TOR,
<br /> Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument, you ars.making S copies.
<br /> 5. Tank owners must submit a plot plan to the !coal agency shoeing the location of the LTSTs with respect
<br /> to tui dirigs andlandmarks marks f2711i (a,(8) CCR ,
<br /> 5. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments tints tc the logcal agency for petroleum USTs [27'191 (a)(i 1) SCR],
<br /> TOP OF FORM: MARK ONLY ONE ;T 17,
<br /> . dark a ( ) in the box next to the item that best def rlbes the reason the form is being completed,
<br /> Indicate the DEA or Facility name where the tank ;,a installed,
<br /> i. TANK D SCIPTI N - COMPLETE ALL ITEMS - IF UNKNOWN - SCT SPECIFY
<br /> A. Indicate owners tank ID _ If'harp- Is a tank number that Is used by the owner to identify the tank(ex.
<br /> AS 0789),
<br /> E. Indicate the name of the company that manufactured the tank(ex, ACME TANK MFG). C
<br /> C;. Indicate the year the talk was installed (ex, 1987),
<br /> S. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc=),
<br /> If. TANK CONTENTS
<br /> A. t IF m r,-., 1 VEHICLE UE-L, check box 1 and complete items B A C.
<br /> S. If not MOTOR VEHICLE FUEL, check f;:e appropriate box in section A and complete Items IS& D,
<br /> B, Check the appropriate box.
<br /> S. Checktho type of MOTOR VEHICLE FUEL f box 1 is checked in try
<br /> }, Fair- the chemical ical name of the [iazardous substance stared in the tank and the C.A.S.#. (Chemical
<br /> Abstract Service number), if box 1 is NOT"3'1:ecked in A.
<br /> Ill, TANK CONSTRUCTION 4 4A'RK 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 /> PROTECTION,
<br /> 2, If OT aER, print in the space provided.
<br /> IV, PIPING INFORMATION
<br /> 1, Chole"A" if above ground circle "U" if i mferground; and circl both if applicable,
<br /> 2. If ttNKr<kOVV'`I €;`y l or if OTHER,ER, pr`nt In space provided,
<br /> 1 Indicate'the LEAK DETECTION syster r)s) used to comply with the monitoring requirement for the piping
<br /> V. TANK LEAK DETECTION
<br /> Indicate ilea I_,EA S�"t EC T ISN Asfr 3aL tc osrr�pf with the monitoring requirements for the tank,
<br /> L INFORMATION ON TANK PERMANENTLY
<br /> CLOSED IN PLACE
<br /> 1, ESTIMATED LATE LAST USED . fvIONTI 1YEA T (January, 1988 or 01/88)
<br /> . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> S. WAS TANK FILLED WITH INERTMATERIAL? Check,ayes"or"No",
<br /> TANK OWNER OR AUTHORIZED I"EPR SE"NTA`"L'VE MUST SIGN AND DATE THIS FORM AS INDI-
<br /> CATED [see section 2711 (a)(i s) CCR
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two€ igit county number,the three digit
<br /> jurisdiction numb er,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are
<br /> prs_gl�jermined and can be obtained by calling the State Board (515)227-4303, The facility number roust be the same as
<br /> shown in form W, The tank number may be assigned by the local agency,however,this number roust be numerical and
<br /> cannot ontalh an alphabet", If the local.agency prefers the State Board to assign the tare number, please leave it blank.
<br /> IT ,I THE RESPONSIBILITY OF THE LOCALAGENCY THAT INSPECTS THE FACILITY TO VERIFY THE A U-
<br /> RA Y 7F;THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE F,OR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INF ATION BOX. THE LSO AL AG N Y SHO LD RETAIN Ti ORIGINAL; AND
<br /> YELLOW COPIES, TIME PINK HOULD BE RETAINED BY THE TANK &ER,
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