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INSTRUCTIONS FOR COMPLETING FQFlM ;"f3"
<br /> GENERAL INSTlT# NS
<br /> Section'2111 of Title 23,"Division 3,Chapter 16,California Code of Regulations 60,01-sections 25286,25287,and 25289
<br /> of`Chapter 6.7,Division 20,Health and Safety Code require tank owners to apply for an UST operating permit.
<br /> IIJ `Ohe F(3'R "8"sW,be completed for each tank for.All.NEW PERM,ITS, PFRMW CHANGES, RBMOVt:.
<br /> ALS ancfPot antr,otter TANK FORMATION CHANGE.
<br /> Z'` This form should becampleted,by either ft PEWIT APPLICANT or:tbe..LOCALAGENCY UNDER=.
<br /> GROUND TANK INSPECTOR.
<br /> 3- -- Please type or print clearly all requested,iaderrnation:..F. .
<br /> 4. Use a hard point writing instrument,you ara making,3 copies.
<br /> r . _ _ 6. Tank owners must submit a plot plan to the local agency showing the locatiort of ft USTs.with-f
<br /> 6 „.
<br /> to buildings and landmarks(2711 (a)(8)CCR , 7 -_
<br /> 6. Tank owners must submit documentation showing compliance with staff;financial respm-mbdr fequirep, d
<br /> meets to the local agency for petroleum-USTs`[2711 (a)(11)CCRI.
<br /> TOP OF FORM: MARK ONLY ONE ITEM ` wAx
<br /> 1. Mark an (X) in the box next to,the item f►at:j*gdescribes the reason the form is beino g;iaie3.
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<br /> r. 2. Indicate the DBA or Facility name where the*nk'is installed.
<br /> is TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIF
<br /> . A. Indicate owners tank ID#-It there is a tank number that is used by the owner to IderlX j
<br /> AB70789),
<br /> h y B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG);
<br /> kll1 .1 11WC. ' "'Indicate the year the tank was installed(ex. 1987). t
<br /> - -D. indicate the tank.capaaty in gallons(ex.25,000 or 10,000 etc.),
<br /> . II. YANk CONTENTS
<br /> A 1: IF MOTOR VEHICLE FUEL,check box 1 and co ins &C.
<br /> 2_If not MOTOR VEHICLE FUEL,check the appropn a big it section A and complete.
<br /> items 8&D.
<br /> w
<br /> B. Ghegklheappropriate box.
<br /> C. Che6k the type of MOTOR VEHICLE FUEL(if;box 1 is checked in A).
<br /> - D-. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical
<br /> :Abstract Service number),if box 1i NOT checked in A.
<br /> TANK CONSTRUCTION- MARK ONE ITEM- ONLY IN BOX A, Br
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<br /> �4 1.. Check only oi,e item in TYPE Org4STEM TANK MATERIAL, IN 4 LINING and CORROSION
<br /> PROTECTION.
<br /> . If OTHER, print in ft`Spam prbo _
<br /> 1V.` PIPING INFORMATIOh1.;
<br /> _ - gw "Circle"A" if abW4 roundU"if
<br /> "u . und, and circle both if applicable.
<br /> .;
<br /> 2 If UNKNOWN circle,or if OTHER,pnrrt ll r provided. -
<br /> 3 Indicate the LEAK DETECTION system(s)used to comply with the monit�-requirement for them�
<br /> V <. TANK LEAK)DEJECTION
<br /> 1. Indicate ik6 LEAK DETECTI( I system(s)used to comply with the monitoftrequirwrtents for#1e:taWk
<br /> VL _ ....NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE-- - - - - -
<br /> �, ESTIMATED40ATE LAST USED-MONTHNEAR (January, 1988 or 01188)}
<br /> 2 ' , ESTIMATED�QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3., `VmArANK`FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> 'T 'iK4, ER AUTHOFIIZED'-REPRESENTATIVE MUST SIGN AND DATETWE FORM AS INDi-
<br /> CATS[see section 2711 (a),(13)CCR]
<br /> IfRUCTION FOR THE LOCAL,."AGENClE
<br /> The state underground storage tank1dentification number is composed of the two digit county number,the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank number. The county and`jurisdiction numbers are .
<br /> predetermined and can be obtained by calling the State Board(916)227-4303. The facility numb4t-must be the same as
<br /> Viown in form"A". The tank number may be,assigned by the local agency,however,this number"must be numerical and
<br /> cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> ' IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIPY'THE ACCU-
<br /> t RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> �","+SAL AGENCY USE ONLY' INFORMATION B,. , THE'LOCAL AGENCY SHOULf3 I ETAIN THE O.BiGINAL. ANC .
<br /> "" 7ELL'OW COPIES. THE PINK Cf BHOULQ F#ETAiNl;D BY THE TAN NFFI ,
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