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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 cfTitle 28.Division 3,Chapter 1G.California Code ofRegulations and sections 252BG,25287.and 2528g of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit. i� One FORM "B''shall becompleted for ahtanktoreUNEVVpERk4|TS,PERK0|TCHAN(3EB.RE��<]Y- ' ALS and/or any otherTANK INFORMATION CHANGE. . 2. This form should becompleted byeither thPERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND 3. Please type orprint clearly all requested information. 4� Use ahard point writing instrument, you are making 3copies. S. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect tobuildings and landmarks [2711 (a)(8)CCR]. ` S. Tank owners must submit documentation showing compliance with state financial responsibility require- ments tothe local agency for petroleum USTe[2711 (a)(11)CCR}. TOP QFFORM: MARK ONLY ONE ITEM 1. Mark an(X)inthe box next tothe item that best describes the reason the form imbeing completed. 2. Indicate the DBA or Facility name where the tank im installed. i TANK DESCRIPTION - COMPLETE ALL ITEMS ' IF UNKNOWN ' SO SPECIFY A� Indicate owners tank !D#-Kthere iaa tank number that |sused by,theowner toidentif/the tank �x. AB70788� ' 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. 25'080or10,000etcj. K. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and 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 ofMOTOR VEHICLE FUEL (if box 1 imchecked inA). D� Print the chemical name ufthe hazardous substance stored inthe tank and the C.A.S.#.(Chemica| Abstract Service nurnber).ifbox 1 iaNOT checked inA. Ui TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, B. C & D 1� Check only one item inTYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, 2� IfOTHER, print inthe space provided. {V. PIPING INFORMATION 1� Circle "A" ifabove ground circle "U"if underground, and circleboth Kapplicable. 2� IfUNKNOVVNcimJe-nrif OTHER, print inspace provided. 3� Indicate the LEAK 6ETECTION 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 PERMANENTLY CLOSED IN PLACE 1 . ESTIMATED DATE LAST USED 'MC}NTH/YEAR(January, 1B88orD1/88) 2. ESTIMATED QUANTITY ofHAZARDOUS SUBSTANCE remaining inthe tank (in Ga||ons). 3� WAS TANK FILLED WITH INERT MATERIAL? Check "Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS |N0~ CATED (see section 2711(s)(13)CCR] 111STRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit colAy 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 LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL YELLOW COPIES. THE PINK C(* SHOULD BE RETAINED BY THE TANK ##'NER.