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INSTRUCTIONS FOR COMPLETING FORM ^B^ GENERAL INSTRUCTIONS Section 2711ofTitle 23. Division 3. Chapter 1S. California Code of Regulations and sections 2528G.25287. and 2528Q 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 each tank tor all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2, This form should becompleted byeitherthePERM|TAPPL|CANTortheLDCALAGENCYUNDER' 8ROUNDTANK|NSPECT{}R. 3. Please type orprint clearly all requested information. 4. Use ahard point writing instrument,you are making 3copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect hobuildings and landmarks(2711 (a)(8)CCR]. G. Tank owners must submit documentation showing compliance with state financial responsibility require- ments tnthe |ona| ugenny/nrpetno|eumUGTo[2711 (o)(11\CCR]. TOP OFFORM: MARK ONLY ONE ITEM 1. Mark an (X) inthe box next tothe item that best describes the reason the form iabeing completed. 2. Indicate the DBA orFacility name where the tank ioinstalled. |. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - S[) SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7O78U). B. Indicate the name of the company that manufactured the tank(*x.ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1Q87). D. Indicate the tank capacity ingallons (ox. 25.000or10.000eto.). ||. 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 iachecked inA). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number). ifbox 1 iaNOT checked inA. |||. TANK CONSTRUCTION - MARK ONE ITEM ONLY |N BOX A, B, C & D 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" if above ground circle"U" if underground, and circle both if applicable. 2. |fUNKNOWN circle; orifOTHER, print inspace 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. V|. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ' 1. ESTIMATED DATE LAST USED - MONTH/YEAR ry. 1Q8BorO1/8@) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3, WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER ORAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 /a\M3\ CCRl INSTRUCTION FOR THE LOCAL AGENCIES The state undergroundstm tank identification ber is composedofthe 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 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TOVERIFY THE ACCU- RACY OF THE CCU'RACYOFTHE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COK�PLET|ON OF THE "LOCAL AGENCY USEONLY'' INFORMATION BOX. THE LOCAL AGENCY SHOUL |N THE ORIGINAL AND YELLOW COPIES. THE PINK COPY �� ULD BE RETAINED BYTHETANKOVV�� ��