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INSIRUCITONS FOR COMPIHrfNG FORM-B- GENERAL INSTRUCTIONS: 1. One FORM "B"shall be completed for each tank for all NEW PERMrI'S,PI?RMrI7 CIIANGES, 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 INSPECTOR 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. 'I.'OP OF FORM.'MARK ONLY ONE LTIW- 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 is installed. 1. 'TANK DFSCRIPITON-COMPUTMI ALL rIT%LS-IF UNKNOWN-SO SPECUry 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(ex.25,000 or'10,000 etc.). It. TANK CONI'FN'I',S A. 1.. If MOTOR VISHICLI:i FUI~,L,,check box I and complete items B R C. 2. If not Mo,rOR VFIIICI.E FUI::L,check the appropriate box in section A and complete items B &D. B. Check the appropriate box. C. Check the type of MC7rOR 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 Abstract Service number), if box I is No,r checked in A. M. TANK CONS.TRUCIION-MARK ONE 17110A ONLY IN BOX A,11,C&D L Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,Iti I'ERIOR LININ(3 and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMA'I1ON L Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTIIER, print in space provided. 3. Indicate the LEAK DSIT3C.'IION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DE'I`EC-nON 1. Indicate the LEAK D1I'ECTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMA110N ON TANK PERMANEN7.11Y CI.OSF.D IN PI.ACE 1. FST7MA'I9iD DATE LAST USED-M(.)N"Tl'1/YEAR(January, 1.988 or 01/88). 2. ESTIMATED QUA.NrlIII'Y of IL-VARDOUS SUBSIANCE remaining in the tank (in Gallons). 3. WAS TANK FILLF,I.7 WT111 INERT'MATERIAL.? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE'I1IE FORM AS INDICAITM. INSTRUCTION POR'111E IAC:AL AGENCII.?S 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 six 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. rr IS TIIE RFSPONSIBII..rr Y OF'171.11 LOCAL AGIr1VCY'1TIA'r INSPECTS T1m FACILrrY TT)VERA Y'LIR; ACCURACY OF'I1IE INFORMATION. TTIE LOCAL AGENCY IS RI SPONSIBLEr FOR THE COMPI.ETION OF'I1IE *LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND AS,SOCI 1171) FORM-B-(s)TO 11IE FOLLOWING ADDRESS. ST/tiI'B OF CALIFORNIA 91WI1?WATER RESOURCES CONI'ROL BOARD C/O S.W.ILILPS. DATA PROCESSING CEMIVR P.O.BOX 527 PARAMOUNT,CA 90M