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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division 3. Chapter 1G. California Code ofRegulations and sections 2528B. 25287. and 25288 ofChapter 6.7. Division 2O, Health and Safety Code require tank owners 10apply for anLIST operating permit. 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE, 2. This form should be completedbyeither the PERMIT APPLICANT orthe LOCAL AGENCY UNDER- GROUND TANK INSPECTOR, 3. Please type nrprint clearly all requested information. 4. Use mhard point writing instrument,you are making 8copies. G. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect 10buildings and landmarks(2711 (a)(8) CCR]. G, Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum USTs [2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark on (X) inthe box next tothe item that best describes the reason the form iebeing completed, 2. Indicate the DBA or Facility name where the tank ie inutaUed. |. 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. 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. 1987). D. Indicate the tank capacity ingallons (ex.25'008or1O.O0Oe&c.). U. TANK CONTENTS A� 1. |FMOTOR VEHICLE FUEL, check box 1and complete items B&C. 2. |fnot MOTOR VEHICLE FUEL,check the appropriate box insection A and complete items B&O. B. Check the appropriate box. C. Check the type ofMOTOR VEHICLE FUEL(if box 1imchecked inA). D. Print the chemical name ofthe hazardous substance stored inthe tank and the C.A.S.#. (Chemical Abstract Service number). i/box 1 |mNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A. B. C & [} 1. Check only one item |nTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2, |fOTHER, print inthe space provided. |V. PIPING |NF0BK4AT|C}W 1, Circle"A" if above ground circle"U" if underground, and circle both if applicable, 2. |fUNKNOWN circle;nrifOTHER, 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 symtemkdused tocomply with the monitoring requirements for the tank V|. INFORMATION ON TANK PERMANENTLY CLOSE[) IN PLACE 1. ESTIMATED DATE LAST USED' MONTH/YEAR (January, 1988or01/88) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining inthe tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check'`Yam"or"No" TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 /a\(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification numbe is dofthe 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)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 LO4GEN�Y !� ��8PON�|8LE FDR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BYTHE TANK OWNER.