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STATE OF CALIFOR* WATER RESOURCES CONTE BOARD i 1 FORM B : :sA UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION u" m i 0 INSTRUCTIONS FOR COMPLETING THIS FORM Fes" GENERAL INSTRUCTIONS: 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, TANK CLOSURES, TANK Z REMOVALS, and/or any other TANK INFORMATION CHANGE. 10 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. TOP OF FORM: "MARK ONLY ONE ITEM" F--� IV 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. Cn 2. Indicate the Facility/Site name where the tank is installed. 3. Is this tank a farm tank? Check'YES' or'NO'. A farm tank is a tank located on an agricultural farm which stores motor vehicle fuel used to propel farm vehicles. I. TANK DESCRIPTION — COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - It 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 tank was installed. (ex. 1987) D. Indicate the tank capacity in gallons. (ex. 25,000 or 10,000, etc.) II TANK CONTENTS A. 1. If MOTOR VEHICLE FUEL, 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 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 1 is NOT checked in A. III. TANK CONSTRUCTION — MARK ONE ITEM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle A if above ground, or U if underground; circle both if applicable. 2. If UNKNOWN, circle or if OTHER, print in space provided. V. LEAK DETECTION SYSTEM 1. Circle P for PRIMARY, or S for SECONDARY. A primary and/or secondary leak detection system MUST be circled. 2. If UNKNOWN, specify or if OTHER, print in space provided. 3. If there is no SECONDARY LEAK DETECTION SYSTEM, circle NONE. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01 /88). 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank. (in Gallons) 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'YES' or 'NO'. Applicant must sign and date form as Indicated. IT IS THE RESPONSIBLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS: STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 3-15-88