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INS1.72UCIIONS FOR COMl'LURNG FORM B" GFNERAL INS RUCTION& 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGFs, REMOVALS and/or any other'TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNI3ERGROUND 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' 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. I. TANK DF-SCRIVIION-COMPLE TE ALL fIT24S-IF UNKNOWN-SO SPECIFY A. Indicate owners tank 1D#-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 CONTENTS A. 1. If MOTOR VEHICLE FUEL,check box I 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 VEI:IICLE FUEL(if box 1 is checked in A). 1). 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. M. TANK CONSTRUCTION-MARK ONE TI'EM 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. TV. 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 DETECTION 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 PERMANEM11M CLOSED IN PLACE I. ESTIMATED DATE LAST USED-MONTTI/YEAR(January, 1988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK MLLFD WITH INERT MATERIAL? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE TME FORM AS INDICATED. INSTRUC I'T ON FOR THE LOCAL 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. IT IS IIID RESPONSIBILITY OF TILE LOCAL AGENCY THt1T INSPECTS TI IE FACILITY TO VERIFY'II-IE ACCURACY OF 179E INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR 11IE COMPLETION OF THE "LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM"A AND ASSOCIATED FORM'B'(s)TO T1IE FOLLOWING ADDRESS. STATE OF CALIFORNIA sm-F wATGR RESOURCES CONTROL BOARD C/o S.W.1:OiP s. DATA PROCM&ZING CENIT?R P.O.13OX 527 PARAMOUNI',CA!ffM