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IN91'RUCIIONS FOR COMP11*1G FORM 'B" L] 0. 4 GENI?RAL INSTRUCITONS- L One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT (71IANG13S, REMOVAUSand/or any other TANK INFORMA1710N CHANGE 1 This form should be completed by either Me PERMIT APPLICANT or the I"Al, AGENCY UN11ERGROUND 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 rllM* 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. L. TANK DF-SCRIFITON - COMP113FIM All. 1`11WS - 117 UNKNOWN - SO SPMIzY A. Indicate owner,,, 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.). H. TANK CONIliMrS A. 1. If MOTOR VE111CIA.". FUFLl check box 1 and 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 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. TIL TANK CONSTRUCTION - MARK. ONE ITEM ONLY IN BOX A, B, C & D I. Check only one item in TYPE OF SYSI'EM,TANK MATERIAL, INTEMIOR LINING and CORROSION PROTECIIJON. 2. If ffnffiR, print in the space provided. IV. PIPING 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 DF-,rucTiON system(s) used to comply with the monitoring requirement for the piping. V. TANK I.EAK DLrl73(7[ION 1. Indicate the LEAK DE'113C71ON system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON `TANK PERMANENTLY (3,OSED IN PLACE L ESTIMA11.1) DATE? LAST USED - MONTII/YFAR (January, 1.988 or 01/88). 2, ESTIMATED QUANT rl'Y of IIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INFKI'M.ATFRIAL? Check 'Yes' or 'NO'. APPLICANT MUST SIGN AND 13NILz 311H FORM AS INDICK11-:13. IN' STRUC711ON FOR'11IF I.,OCAI, AGENCIES 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-. 1I'IST11E RESPONSIBUXI'Y OF 111E LOCAL AGENCY 11INFINSPIX-IS *ITIE FAC1111"Y TO VERIFY'llIE ACCURACY OF ITIE INFORMN.110N. 11113 I)OCAL AGENCY PS RESPONSIBIM FOR'11111 COMPIX.'11ON OF ITIS "LOCAL AGENCY USH ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A' AND ASSOCINIFI) FORM 'IP(s) -17011111, 17011A)WING ADDRESS. 917KII! OF CA11FORNIA 9FA711? W)V173R RESOURCES CON71tOL BOARD C/O S.Wlli E.P.S. DATA PRO(MSSING CE: NI'F.R P.O. IX)X 527 PARAMOUNT, CA 90723