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�T7 INSTRUCTIONS FOR FOR COMPLEFNG FORM ^B" GENERAL INSTRUCTIONS _ - � Section 2711 ofTitle 23. Division 3. Chapter 1S. California Code ofRegulations and sections 2528G.25287. and 26288 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 becompleted for tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should bocompleted byei1herthePERM|TAPPL|CANTordhoLOCALAGENCYUNDER' GRDUNOTANK |NSPECTDR. 3. Please type orprint clearly all requested information. 4. Use ohard point writing instrument, you are making 3copies. 5. Tank owners must submit aplot plan tothe local agency showing the location ofthe USTnwith respect tobuildings and landmarks[2711 (a)(8)CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- mentstothe|ooa|agenoyforpegno|eumUSTo[2711 (a)(11)CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) inthe box next tuthe item that best describes the reason the form iobeing completed. 2. Indicate the DBA or Facility name where the tank iainstalled. |. TANK DESCRIPTION ' COMPLETE ALL |TEK8G - IF UNKNOWN - SC} SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O789). B. Indicate the name ofthe company that manufactured the tank(ex. ACME TANK MFG). C. Indicate the year the tank was installed (ax. 1987). D. Indicate the tank capacity ingallons(ex. 26.000or10.000etc.). ||. TANK CONTENTS A. 1. |FMOTOR VEHICLE FUEL, check box 1and 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 ofMOTOR VEHICLE FUEL(if box 1 iochecked inA). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.G.#. (Chemica| Abstract Service number). ifbox 1 iuNOT checked inA. |||. 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. ' 2. |fOTHER, print inthe space provided. |V. PIPING INFORMATION 1. Circle"A^ ifabove ground circle"U" ifunderground, and circle both ifapplicable. 2. |fUNKNOWN circle; orif OTHER, print inspace provided. & 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. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED' K4ONTH/Y (January, 1988or0108) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check^Yeo^or^No^ TANK OWNER DR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state undergroundoto tank identification number is d ofth two digit county numberthe three digit jurisdiction.number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are redetermined and can be obtained by calling the State Board(9The facility number must be the same as shown inform "A^ The tank number may beassigned bythe local agency,however,this number must benumerical and cannot contain analphabet. If the local agency prefers the State Board 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- RACYOFTHE 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 C SHOULD BE RETAINED BYTHE TANK 4 NER'