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INSTRUCTIONS FOR COM LE i FOS "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 15, California Code of Regulations and sections 25255,25257, and 25259
<br /> of Chapter 5.7, Division 20, Health and Safety Godo 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 TANKNFORM TI CHANGE,
<br /> 2. This form should be con plated by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERm
<br /> F
<br /> GROUND TANK r SPECTOR,
<br /> i✓nfR,
<br /> 1 Please typ ,_, .i„', rr 1. e, crested inm r# ion,”
<br /> 4, Use a hard point wiir nq n�tra.rrr,,ent, you e making 3 copies..
<br /> 5. Tank owners must sr brnit s plot plan to the i��c l agency howin the location f tine l��°T with respect
<br /> to buildings and iandm rks[',??711 f(8) ,
<br /> S, Tank ownersiron u4w it documentation showing compliance with state financial responsibility require-
<br /> rpents to the.local agency for petroleum RISTs[271 1 (1 OCR],
<br /> TOTS & FORM., MARK i it y ONE ITEM
<br /> 1. Mark an in the box nem to the item that best describes the reason the form is being completed,
<br /> 2. Indicate the DSS or Facilit �; niwhr the tank is-i Called,
<br /> 1. TANK E I TI N - COMPLETE ., LI— ;T EM - IF UNKNOWN - SO SPECIE
<br /> A, Indicate owners tank ID 5¢X77 , _e `,.r d�t"r ri , I1e, that s w used by the owner to identify the tank(ex,
<br /> S, Indicate the name th ., mp. .° th,,,it the tank tea ACME T NKFG),
<br /> Cs Indicate the year the tank was iristalled (Axe 1987),
<br /> 3. Indicate the tank capacity in gallons (ex"25,035 or 10,000 etc.). _
<br /> II, TANK ITE TS
<br /> A. 1. IF MOTOR VEHICLE FU2I ; c hack box 1 and complete items S&C.
<br /> 2. If not1�r"g OR VEHICLE a i t,t.,, dh.tr,,r he appropriate box in section A and complete item .
<br /> S. Check tr e appron£ .ita is:jx,
<br /> Check the type of F11 t.... 4"if box x } is checked in .
<br /> . Print the chemical name of substance stored in the tank and the " .S. " (Chemical
<br /> l
<br /> Abstract Service number), i" box s NOT checked in Aa
<br /> III, TANK CONSTRUCTION'�-MARK ONE ITEM ONLY IN BOX A, ,
<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 spate provided,
<br /> �, PIPING INO5 1 y'ON
<br /> 1. CircleA'' if above ground 6,r i>r°_"I.11"sf k dergroun ,and circle b of if applicable..
<br /> 2. IfUN UNKNOWN �" o. ,f ORlE,N, ,dirtispace,.
<br /> .
<br /> 3.
<br /> Indicate t[" _., , ,t s"I s) used to comply witht"TF monitoring requirement for the piping.
<br /> V, TANK LEAK ETt CT a.,,
<br /> 1, Indicate the LEAK t,r i E 1 i0lxi system(()used k cornpiy with the monitoring requirements for the tank.
<br /> yrl, INFORMATION N TANK PERMANENTLY CLOSED Its PLACE
<br /> 1.a ESTIMATED DST E 1 kS US l r (January, 1353 or 01135)
<br /> 2, ' ESTIMATED QUANTITY ITT of A L )US SUBSTANCE remaining in the tank in Gallons).
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes'or"No". 4
<br /> TANK OWNER E OR AUTHt:gFUF:ED REP'P`4ESEN'I.A%TIVE MUST SIGN AND DATE `°TIDE FORM AS INDI-
<br /> CATED
<br /> I-
<br /> C:.T tg (sea section 2711 a)(1 3) CCR
<br /> fw,l TyLf Tl hl FOR THE LOCAL.L.. Gc.l f..,IES
<br /> he state underground storage tank ide "tific rio. .s number is composed of the two digit coerity number,the three digit
<br /> jurisdiction number,the six digit f acili y nurnbei ,,"rid the six digit tank number, The county,and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(916)227-4353. The cility number must be the wino as
<br /> shorn in form'A". The tank number may be assigned by tiro local agency,however,this number roust be,numerical and
<br /> cannot contain orf alphabet. If tb IcTda,1 agar= y srotoro the Store Board to assign the teak number, please leave it bleak:
<br /> IT IS THE RESPONSIBILITY tit THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFYTHE ACCU-
<br /> RACY
<br /> ACY THE INFOWA.TION, Tl d �L CAL ENC IS RES tSIBLE FOR THE COMPLETION THE
<br /> LS I ,AGENCY ULE ONLY' !NFORSAT ION _X, THE LOC..le, AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELEOW COPIES, THE PINK COPY SHOULD BE RETAJNED BY THE TANK OWNER.
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