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INSTRUCTIONS FOR COMPLEOGFOS "B
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286,25287, and'26289
<br /> of Chapter 617,Divi4ion 20, Health lth rid Safety rode require teak owners to apply for ars USS operating permit,
<br /> 1 FORM "shall b completed for each tank for all NEWPERMITS, PERMIT CHANGES, REMOV-
<br /> ALS
<br /> ` . yother TANK tl HE,
<br /> . This form should be completed by either'ho PERMIT A IRPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> g. Please re pe or pT4 ,-1eady tt rroquested into;;`anon.
<br /> 4. . Use a hard point writing id troy dnt,you ire making 3 co io e' "
<br /> 5, Tank owners must submit a plat plan to the local agency showing the location of the LIST°5 with respect
<br /> to buildings and landmarks[2711-(a)(8)CCR],
<br /> ),
<br /> 5. Teak o nor ,must submit documentation shoeing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum € ` [2711 (a)(1 1)CCR],
<br /> TOP OF FORM: MARK ONLYONE ITEM
<br /> 1. Mark an (X) in the box next to.the item that beat describes the reason the or is being donpl t da
<br /> pa Indicate the DBA or Facility nar - h r the tank ia,ggstail da
<br /> IA TNI DESCRIPTION IPTPION - COMPLETE ALL ITEMS - IF UNKNOWN - S SPECIFY
<br /> .. Indicate owners tank ID if there is a tank number that is used by the owner to identify the teak .
<br /> ; 7 789),
<br /> Indicate the name of the company that ma.noftiaot rod the tank(ex.ACME TANKMFG),',,
<br /> C. Indicate the year the tank was installed (ex, 119=87).
<br /> D. Indicate the tank capacity in gallons ,25,000 or 10,000 oto,),
<br /> I . TANK CONTENT
<br /> A. 1. IF MOTOR VEHICLE L.E"FU L,check box 1 and complete items B&C.
<br /> Z if not MOTOR VEHICLE FUL=L,chock the approprato box in section A and complete items B&D.
<br /> B. Chock th sp ro pri to hex.
<br /> Chock 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 .A, . .a (Chemical
<br /> Abstract Service number),if box 1.ia NOT checked In
<br /> Irl, TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, B,
<br /> 1 Check only one item in TYPE OF SYSTEM, MATERIAL, INTERIOR LINING and CORROSION
<br /> g., if ` HERE print in the apace provided,
<br /> IxymPIPING INFORMATION
<br /> 1, Circle,"A" if above ground circle"Ll"if underground,and circle bots if applicable,
<br /> , If UNKNOWN Ntx WN circle; or if OTHER, print in space e prop°idd.
<br /> , Indicate the LEAK DETECTION system(s) used to comply with ttTe monitoring requirement for the piping.
<br /> `4 TAN' "�`LEASE DETECTION
<br /> 1. Indicate the LEAK CTI N system(s)used to comply with the monitoring requirements for the tank.
<br /> Vim INFORMATION Of TANK PERMAINEN TILY CLOSED IN PLACE
<br /> `l„ ESTIMATED DATE LAST USED, O THA`EAt (January, 1988 or 01188"
<br /> ESTIMATED QUANTITY of HAZA00OLIS SUBSTANCE remaining in the tank in Gallons).
<br /> , WAS TANK FILLED WITH INERT T ERI L Check g es"or"Nos,
<br /> TANK OWNER OR AUTHORIZEDREPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [sae section 2711 ( )(1 ) CCR
<br /> l TRUCTION FOR THE LOCAL AGENCIES
<br /> e state underground storage tank identification number is cor posed.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 91 ) 7m4505. The facility nu rnust`bo the same as
<br /> shown in fora"A". The tank number may be assigned by the!coal agency however,this nurrrbor rrrd5t be numerical and
<br /> cannot contain an alphabet, ii the local noy prefers the Stets Board to assign the tank number,please leave it blank;
<br /> IT IS THE RESP0 3 IbILITy OF THE, LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY
<br /> F"TORf,,6 0N, T" E L L AGENCY l tTE F NSI LE FOR THE COMPLETION F THE
<br /> lF Lt L AGENCY USE ONLY', INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW tOPIES. THE PINK COPY SHOULD RETAINED BY THETANK OWNER.
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