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INSTRUCTIONS FOR COMPLI&IG FORI'v` 711
<br /> GENERAL INSTRUCT
<br /> Cier.,Jion 2711 of Title 23, Dims i-,'r 6, Code ,)r ul-t �spct c,$l ns 25286, 25287, and 25289
<br /> c1 Chapter 6.7, Division 20, wre tank own to apply nrn,�,n U13 l"operating perrnit,
<br /> 1. One FORM "BI o--lete, tnr each tank for zfl, NE�Af PEiRMI fz-, C1,4ANGES, REMOV-
<br /> ALS and/or an,,, ,F(,,, �!A,T�ON CHANGE.
<br /> 2. This form shot-
<br /> he PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND T,,'il
<br /> 3. Please hypo
<br /> 4. Use a hard "I writing in" `""menz, 3 copies
<br /> 5. �enGy h," ::gig the location of the UST s with respect
<br /> 6e rh""
<br /> cg complianc-0 with state financial responsibility require-
<br /> "'j tf.11 USIs 4k711 (a)(1 1) C P.
<br /> M
<br /> TOP OF FORM: MARK
<br /> 1 P Mark an �,a" caxf to to . itsm that best describes the reason the form is be4ig completed.
<br /> 2. Indicate the DBA cir Facility n;=rrne where the tank is installed.
<br /> TANK DESCRIPTION - COMPLETE ALL ITEMS ® IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank 0#- If ��s a tank number that is used by the owner to identify the tank(ex.
<br /> AF7(:i78�-011
<br /> the
<br /> nuf Mired the tank(ex. ACMETANK MFG),
<br /> D
<br /> '3'!";i!V�P 25,000 or 10'000 etc.),,
<br /> Ilo TANK TENTS
<br /> A. 1, 1F e'J--Han
<br /> ICLE FUEL, check box 1 d complete items B&0,
<br /> FH
<br /> 2, �"- , 1� "T
<br /> � VICLE FUEL, check theappropriate box in section A and complet'a4ems B& 0,
<br /> B.
<br /> C, Check the Lipp YCOR IVEHICLE FUEL if box 1 is checked in A).
<br /> DPrint the chemical of the hazardous substance stored in the tank and the C.A,S,#, (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> Ifl. TANK CONSTRUCT ION - MARK 0t,!F-- ITEM ONLY IN BOX A, B, C & D
<br /> 1 Check ow-, ':'em in T „,,,,C TEM,T ANK MATERIAL, If LININ G and CORROSION
<br /> 7
<br /> rnc,,reong reqtArernmnt tor the piping,
<br /> V. TANK LEA-�
<br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED - MONTH/YEAR(January, 1988 or 01/88)
<br /> 2, ESTIMATED QIUAN'7ITY of HAZkiFRD'0,L)S SUBSTANCE remaining in the tank(in Gallons),
<br /> =417 t'AAT ERIA' Check"Y ;”or"No
<br /> 1 WAS TANK FILL!, "!
<br /> TANK OWNER OR -,r. PIRSENT'ATIVE 1',,'11UST SIGN AND DATE THE FORM AS INDI-
<br /> CATED fse�3 2-711',1 (1'1'"Rj
<br /> 7 ��,OENCIES
<br /> INSTRUC' P<)R T E--
<br /> nurrt';-'r;s oGI—,sed cf the two digill the three digit
<br /> .t.da. anQ' C:'-, number. The county and IUdsdiction numbers are
<br /> t s'-,Vst dl 1 2-27 i'vll '91P _AQ .1 T he facility-numbermust be the same as
<br /> �N
<br /> N z sic
<br /> 4f L'the loca�arjencv, however,this number must be i-I u ni er cal and
<br /> wq nir"-)-
<br /> '1 05— ni ern - -ve it blank,
<br /> J',,e to n' -ier, please!ea
<br /> THE RE, P"
<br /> V
<br /> PIE ".P CIL TO VERIFY THE A0,
<br /> 8 FOR T 'E CIOMPLETiON OF THE
<br /> - A RES' 'O
<br /> J L -'--:;Y SHOULD RETAIN 'THE 01RIGINAL AND
<br /> 1 -p r z i-r) 7,4 9" A,!K - WNEC R,
<br /> rte:, T N 0 "
<br />
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