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INSTRUCTIONS FOH COMPLETING FORM'S"
<br /> GeNt8AL lNST L Tnt
<br /> q , n 2711 of Tide 23,Division 3,Chapter 16,California; ode of Regulations and sections 25236,25237,and 25239
<br /> of l apter 3.7,Divilsion 20,Health and Safety Code require tank oWhort to apply for ars LIST operating permit
<br /> 1 M
<br /> One FORM'S"shall be completed for each tare for all NEW PERMITS,PERMIT CHANGES, REMP, �
<br /> AL3 arnd/or any other TANK INFORMATION CHANGE.
<br /> 2. TSIs fo rm shoe ld be completed by either the PERMIt APPLIdIAINTouthe LOCAL AGENCY LINDER-
<br /> GRO DTANK INSPECTOR.,
<br /> 3, Please;type or print clearly all requested information,
<br /> . Use a hard point writing instrument,you are t akirn ,cople&
<br /> . Tank owners must submit a plot plant to the local a efnoy aho i g the location of the l T" with resp
<br /> to buildlogs and landmarks(2711 (a (3)CCAJ.
<br /> 5, Tank owners must submit do a nerntatiorn sho log com li witha to financial r prf ,, billt re ulr -
<br /> ertts td the foal agoo for etrolurrn 13s X2711 ( )(11)
<br /> OF
<br /> a L E IT:
<br /> 1.. ark. ., )in the box next tot e item that beat describes ft re sorn the form is be *K,
<br /> Irndn `te, . DBA or Facility name wher6 the link is,f II
<br /> lm T' NK C3 RI TTO - 'COMPLETE� RL ALL, I Ll t« � �I �`_, .,
<br /> A. Indicate mere tank I �
<br /> If there f a tank anti � u � � <d� r to nder:;��";� �(ex.
<br /> 70789).
<br /> lhdt` tthe name of the company that mahufactured,the,tank,{ex.ACM
<br /> 8TANK,MFG1''�.
<br /> C. Indicate tine year the tank was installed(ex. 1987).
<br /> Indicate the tank capacity in gallons(em 25,000ori}, t ,)s
<br /> . TANK CONTENTS
<br /> m 1� ! 'MOTORVEHICLE FUEL,ohedk box I and complete ite s
<br /> . ff not MOTOR VEHICLE ,check the appropriate, Iu section A and cornp! to iters B&D.
<br /> B. Check the appropriate box.
<br /> Check of T lL R LI(if ilk ip )m
<br /> t chemi cal ame of the h ardous sd stance stored In taenk and the a(Chemical
<br /> rn
<br /> Abstract e i e number),if box 1 1s;NOT checked inn Am
<br /> 11. TANK CONSTRUCTION-MARK ONE, ITER ONLY, IN,BOX Ay":
<br /> 1. Check only one item in R R T° MATERIAL,
<br /> IAL, 1. LINING and CORROSION
<br /> PROTECTION.
<br /> 2, If OTHEA;'pritit in the space provided.
<br /> I , PIPING INFORMATION
<br /> I. role" if ab e gros rid oir le"Lf"If€ riderrodrn r s e,, a tlo Iea .
<br /> 2. Llttl�€circle;dr It i�T k ,print in pace prsyl �da
<br /> 3, n ' sys rn(s)`eased to Comply,..
<br /> kh It monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the'LEAK DETECTION system(s)used to comply monitoringrequirements,for the to
<br /> eta INFORMATJONbN TANK : T'L Y CLOSEDAN
<br /> 1. � rE DATE
<br /> LAST t a N T (January,1 ' 1/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUS&W615 romai kig 16,,the 16,, tank(in Gallons).
<br /> 3. WAS TANK FILLED WITH INERT T" I L7 Check ee or* o"
<br /> I T" TTS t THE FORM AS, I I-
<br /> T (see section 271 '( (1
<br /> INSTRUCTIFORTHIE,LOCAL AGENCIES
<br /> The state underground storage tarn identification' rn rrn r is composed,of the p digit county number,the three dl' it
<br /> `
<br /> jurisdiction number,the six digit facility number and te six digit tank cumber, The,countyand jurisdiction numbers are
<br /> predetermined and can be obtained by callingthe,State Board(919) 7 Ti. The facility number must be theame as
<br /> shown in o " "* tank number may be assigned by the local agency, o e r,'th`n number'must be numerical and
<br /> cannot contain an alphabet. If the local agency prefers the Mate Board to assign the.tank number,please leave it blank:
<br /> IT IS,THE RESPONSIBILITY OR THE LOCAL. AGENCY THAT I T'3 °748 A ILL TO VERIFY THE,A to-.
<br /> RACY THE IN ATTI N. T'H LO L. AGENCY I RESP I THE 'COMPLETION OF THE
<br /> LOCAL N L13 DRILY" I IR 4AT"I I BOX. T H LOCAL AGENCY !I IL . Alli T H 'ORIGINAL AND
<br /> LiCOPIES. THE VINIC HLiL AIN Y T° TA ,,r, NSR .
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