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INS'T RUCI7ONS FOR COMPLETING FORM'B" GFNT?RAL INSTRUCMNS. 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGIrS, REMOVALS and/or any other TANK INFORMAITON CHANGE. 2. This form should be completed by either the PFR?AUAPPLICANT or the LOCAL AGENCY UND ERGROIJND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP Of'FORM/- 'MARK ONLY ONE ITFm 1. Mark an (X) in the�oh��xt to the item that best describes the reason the form is beingSompleted.. 2. Indicate the DB.N oi-F cility name where the tank is installed. 1. 'TANK DESCRIPITON-C:OM HM?ALL ITEMS-TF 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 that manufactured the tank(ex.ACME TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons�cx.,25,000 or 10,000 etc.). II. TANK CONTENTS A. 1. If MOTOR VEHICLE FUEL, check box 1 and complete items B &:C. 2. If not MOTOR VEHICLE FURL,check the appropriate box in section A and complete items B& D. R. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number),if box 1 is NOT checked in A. tiff. TANK CONST'RUCIION-MARK ONE I'IT?..M ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTILER,print in the space provided. IV. PTPING 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 LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANFNTLY CLCGrM IN PLACE 1. ESTIMATED DATE LAST USED -MON111/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WI'III INERT MNI'FRIAL?Check'Yes'or'NO'. APPLICANT MUST'SIGN AND DATE TTiE FORM AS INDICATED. INSITtUCTTON I7OR TILE LOCAL AGiUNCIIa 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 thcSix digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91Ct)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 kcal agency prefers the State Board to assign the tank number,please leave it blank. IT IS THE RESPONSIBI]M Y OF TILE LOCAL AGENCY THAT INSPECTSTHE FACILI'T'Y TO VEI&Y`'I,Ilit ACCURACY OF TIIE INFORMAITON. THE LOCAL AGENCY IS RESTONSITILE FOR TATS COMPLETION OF TIIE "LOCAL.AGU14CY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONP FORM'A"AND ASSOCIATED FORM'B"(s)TO Tr EE,FOtJDWING ADDRF.W STATE OF CAI.I]DRNIA STATI?WNFER RESOURCES CONI'ROL BOARD C/O&W.I?F..PS. DATA PROCESSING CIWI'ER P.O.BOX 527 PARAMOUNT,CA 90'T1.3