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INSTRUC11ONS FOR COMP119c, FORM'B" GENERAL INSTRUCnONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PF.RMrf*CIIANGES, REMOVAI-Sand/or any other TANK INFORMA'11ON CHANGE 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK INSPECT 1`0R- 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 1717IN" L 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. 1. TANK DI SCRI1y1TON-COMPLE17,4 ALI.rl'EMS-IF UNKNOWN-SO SPECIFY A, Indicate owners 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.ACMETANK 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.). 11. TANK CONIWIIS A. 1. If MOTOR VEHICIA], FUEL,check box 1 and complete items B&C. 2. If. not MOTOR VEI-116,14'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. III. TANK CONS'.MUC130N-MARK ONE ITEM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,IN113RIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. IV. PIPING INFORMA711ON 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 DEFEcriON system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DHrV(711ON 1. Indicate the LEAK Drrimcrm system(s) used to comply with the monitoring requirements for the tank. VI. INIXORMN11ON ONTANK PERMANENI'LY 0A)SED IN PLACE 1. ESTIMNJIM DATE LAST USED -MONTII/YEAR(January, 1988 or 01/88). 2. ESTIMATED QuANTrry of HAVARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes'or'NO'. APPIJ0Wr MUST'SIGN AND DW1111 71111 FORM AS INDICATED. INSTRUCTION FOR 11111 1A)CAL AGENCTF-S 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 Sta+e Board to assign the tank number,please leave it blank. rr is TIIE RESPONSIBHXl'Y OFTIIE LOCAL AGENCY 711ATINSPIX.I'S TJJF FACHIINTO VEREIIYJIIE ACCURACY OF11IE INFORMN.110N, T111.11 LOCAL AGENCY Is RESPONSIBLE FOR'111E3 C OMPIrlION OF TIDE 'LOCAL AGENCY USE ONLY"INFORMNIION BOX AND FOR FORWARDING ONE FORM 'A*AND ASS0 (711AIV-D FORM -B-(s)TD 11111 FOLLOWING ADDRESS. STATE OF CALIFORNIA STIVII!WXI1:,-R RESOURCES C!ONI'ROL BOARD C/O&W.EF-P.S. DATA PRO01SSING(I!NrFR P.O.BOX 527 PARAMOUNT,CA 90M