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INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286,25287, and 25230 of Chapter 6.7, division 20, Health and Safety Code require tank owners to apply for an UST operating permit. I. One FORM "B" shall be completed f r, ach tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any ether TANK INFO RMAtION CHANGE. , 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND N ER- GRO .IND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making-3 copies. � Tank owners rn stt. ubmit a,plot plan to the local agency showing the location of the LISTS with respect to buildings And landmarks[2711 ( )(6)CCR],.__ 6. Tank owners mast submit documentation showing cornpl€a ce with state financial responsibility requiretl menu to the local agency for petroleum IJSTs[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITE 1. ark an(X) in the box next to the item that best describes the reason the form is being completed. Indicate the DBA or Facility'arae ere the tai 'igi1ristalled. I. TAMC DESCRIPTION m COMPLETE ALL ITEMSm .IF UNKNOWNCI A. Indicate owners tank ID#®If there is a tank number that is used by the owner to identify the tank(ex. A 773 )e, B. Indicate the/lame of the company that manufactured the tank( x.ACME TANK MFG). C. Indicate the year the tank was installed(e . 1987). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). If. TANK CONTENT A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items B&C. . if not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D.. E. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked.jn 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' 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION 'PROTECTION. ' : If OTHER,print in the apace provided. IV. PIPING" INFORMATION 1. Circle"A"if above ground circle"L1" if underground, and circle both if applicable. . If UNKNOWN-circle; or if OTHER, print in space provided. ` 3. Indicate the LEAK DETECTIONsystem(s) used to comply with the monitoring requirement for the piping. V. TANK LEAD DETECTION 1. Indicate the LEAK DETECTION s stem(s)used to dbli ply with the.monitoring requirements for the tank. VI. ANFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED® MONTHNEAI (January, 1988 or 01188) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). . WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE ,MUST SIGN.AND ®ATE THE FORM AS INDI- CATED [see section 2711 (a)(1 ) CCR] INSTRUCTION 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)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 east be numerical and cannot contain an alphabet. If the local agency prefers the Stateoard 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 AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK *Y SHOULD RE RETAINED? BY THE TAN 4 WN R.