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INSTRUCTIONS FOR COMPLETING FORM "B^ GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division 3` Chapter 1S. California Code ofRegulations and sections 25286. 25287. and 2528A of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FORM ^B^ shall becompleted for each tank for all NEW PERMITS, PERMIT CHANGES, REIMOV' ALS and/or any other TANK INFORMATION CHANGE. 2. This form should becompleted byeitherth* PERM|TAPPL|CANTordhoL{JCALAG\ENCYUNDER' GRDUNDTANK |NSPECTOR. 3. Please type orprint clearly all requested information. 4. Use ehard point writing instrument, you are making 3copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks[2711 (a)(8)CCR]. 8. Tank owners must submit documentation showing compliance with state financial responsibility require- mentstotha |000| agenoyforpetro|eumUSTa [2711 (a)(11) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank ia installed. |. TANK DESCRIPTION - COMPLETE ALL |TEK4G ' IF UNKNOWN - 8O SPECIFY 4, Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O788). B. Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1Q87). D. Indicate the tank capacity ingallons (ax. 25.000or10.000etcl |i TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B&C. 2. |fnot MOTOR VEHICLE FUEL, check the appropriate box insection Aand complete items B&D. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL(if box 1 inchecked in4). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1 ioNOT checked inA. |||. TANK CONSTRUCTION ' MARK ONE ITEM ONLY IN BOX A' B' C & [} 1. Check only one item inTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. |fOTHER, print inthe opao*pmvided. |V. PIPING INFORMATION 1. Circle "A" if above ground circle"U" if underground, and circle both if applicable. 2, KUNKNOWN circle; orifOTHER, print inspace 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. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED ' MONTH/YEAR (January, 1988or01/88) 2. ESTIMATED QUANTITY ufHAZARDOUS SUBSTANCE remaining inthe tank (in Gallons). 8. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes" or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (u)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification be is composed of the digit bethe three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)227-4303. 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU' 'RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATIONBOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK C[�� SHOULD BE RETAINED BY THE TANK��/NER.