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INSTRUCTIONS FOR COMPLETING FORM "810
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulations and sections 25235,25257,and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank b rmers to apply for an LIST operating permit.'
<br /> 1. One FORM"S"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, SEM'
<br /> ALS and/or any Cather TANK INFORMATION CHANGE,
<br /> Z This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> . Please type or print clearly all,requested information.
<br /> 4. Use a hard point writing instrument,you are making,3 copies.
<br /> 5. Tank yawners must submit a plot plan to the local agency showing the location of the IST with respect
<br /> to buildings and landmarks(2711 (a)(9)CCPD,
<br /> 6, Tank owners must submit documentation showing compliance with stare financial responsibility,require-
<br /> ments to the local agency for petroleum US°Ts[2711 (a)(11)CCRI.
<br /> TOP OF FORM: MARK ONLY ,ONE ITEM
<br /> 1; Mark art(X) in the box next to the item that best describes the reason,the,form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank Isinstalled.
<br /> I. TANK DESCRIPTION - COMPLETE ALL I - IF UNKNOWN SPECIFY
<br /> A. Indicate owners flank I -If there is a tank number that is used by the owner to identify the tank(ex.
<br /> 70759).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG).
<br /> C. Indicate the year the tank was installed(es 1987).
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).
<br /> IL TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check bo '1 and complete itemCa
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in' section A and complete Items B&D.
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<br /> C. Print the chemical name of the hazardous-substance stored in the tank and the C.A.S . (Chemical
<br /> Abstract Service number),if box lis NOT checked in Aa
<br /> III. TALK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, B, C & I
<br /> Check only one itern in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION,
<br /> PROTECTION.
<br /> 2. If OTHER,print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1. Circle'A"if above ground circle"U"if underground,and circle both if applicable.
<br /> 2. If UNKNOWN circle;or if OTHER, print in space provided"
<br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the ipirig.
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to corrmply with the monitoring requirements for thetank.'
<br /> L INFORMATION ON TANK PERMANENTLY CLOSEDIN PLACE
<br /> 1. ESTIMATED SATE LAST USED- ' GNTHNEA (January, 1988,or 01183)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUSSUBSTANCE remaining in the tank in Gallon),
<br /> . AS TANK FILLED WITH INERTMATERIAL? Check"Yes"or`�No",
<br /> "TALK OWNER ORAUTHORIZED REPRESENTATIVEUST SIGN AND DATE,THE'FORM AS IN I-
<br /> TED (see section;2711 a)(13) CCR]
<br /> INSTRUCTION FOR °TIDE;LOCAL AG NCI
<br /> The state underground storage tank identification number is composed of the two digit county numb or',the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank number. Thie county and jurisdiction numbers are
<br /> predetermined,and can be obtained by calling the State Board(916)227-430& The facility number must`be the same as
<br /> shown info "A". The tank number may be assigned by the local agency however,this number must b riu meri I 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 #AGILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONL`0 INFORMATION BOX. THE LOCAL A ENCY SHOULD AIN THE ORIGINAL AND .
<br /> YELLOW COPIES, THE ,FINK Y SHOULD.BE RETAINED BY THE TAN 8R.,
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