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INSTRUCTIONS FOR COMPLE-0 FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16,California Code of Regulations and sections 25286,25287, and 25289 of Chapter 6.7,Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit, 1, One FORM"B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR, 3. Please type or print clearly all requested information, 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the UST s with respect to buildings and landmarks[2711 (a)(8)CCR]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum UST s[2711 (a)(11)CCR), 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 DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID m 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 (ax,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.). [I. 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 N110TOt2 FUEL(if box 1 is checked in A), D. Print the chemical name )f dina hnzardous Substance stored in the tank and the C.A.S.#. (Chemical I Abstract Service number), if box 1 is NO checked in A. Ill. 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, ORROSIONPROTECTION, 2. If OTHER, 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 circlea or if OTHER, print in space provided. 3. Indicate the LEAK DEI ECTION systern(s) used to comply with the monitoring requirement for the piping. VTANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMIANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED- MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOU'S SUBSTANCE remaining in the tank(in Gallons), 3. WAS TANK FILLED WITH INERT MATEPIAL'? Check'Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(!3) CCR) :1114STRUCTION FOR THE LOCAL AGENCIES ;'fie state underground storage tank identification number is composed of the two digit county number,the three digit risdiotiors 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 Soard-(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 must be numerical and -annot conNz an alphabet. If the kioN s cy prefers the State Board to assign the tank number, please leave it blank. IT IS THE l4i1S1eOIQklfYr(3iFTHiZLQ.C 'A4-E6� THAT INSPECTS THE FACILITY TO VERIFY THE ACLU® RA(;�4.OF.TjlE INI40R�AA-hOk THE LOCAL AGENCY-IS RESPONSIBLE FOR THE COMPLETION OF THE �:'AOENCY USE ONLY' INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER.