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INSTRUCTIONS FOR COMPLETING FORM'B' GENERAL INSIRUCIIONS: 1. One FORM"B"shall be completed for each tank for a0 NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTUR 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you an making 3 copies. TOP OF FORM:'MARK ONLY ONE II EW 1. Marl:an (X) in the box,next to the item that best describes the reason the form is being complcted. . 2. Indicate'the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION-COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. Indicate owners tank ID# - If there is a tank number that is used by the owner to identify the tank(ex.AB70789). B. Indicate the name of the company thal-manufactured the tank(ex.ACME TANK MFG.). -'•\ . C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). H. TANK CONTENTS A. 1. If MOTOR VEHICLE?FUEL,check box 1 and complete items B &C. 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B& D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstruet Spvice number),if box 1 is NOT checked in A. TIL TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TANItMATERIAL.INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION 1. Circle A if above ground;circle U if underground;and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. V. 'TANK TEAK DETECTION ' 1. Indicate the.LEAK DLTECIION system(s)used to comply with the moliiforing requirements for the tank. VI. INFORMATION ON TANK PQRMANF.NTLY CLOSED IN PIACE I. ESTIMATED DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE 11111 FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the Tix digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form "A'. The tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. IT IS 111E RESPONSIBILITY OF'ITIE LOCAL-AGENCY`11AT INSPECTS'HIE FACILITY TO VERIFY ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 71E13 COMPLETION OVF TETE 'LOCM.AGENCY USE ONLY'IP44ORMAI ION BOX AND FOR.FORWARDING ONE:FORMA'AN)ASSOCIATED FORM-B'(s)TO 17M FOLLOWING ADDRESS. STATE OF CALIFORNIA .. , •� s�X,,y r STATES WATER RESOURCES CONTROL BOARD, C/O SW.E.EP.B. DATA PROCESSING CENTER P.O.BOX 527 . - PARAMOUIk CA 90723 '•,