|
INSTRUCTIONS FOR PLF FC 4694
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division a,Chapter 16, California Code of Regulations and sections 25286,25287, and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit,
<br /> t. One FOR "B"shall be completed for each tank for all NEW PERMIT'S, PERMIT CHANGES, -
<br /> AL and/or any other TANK INFORMATION IAN .
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> NDE -CPC.U TANK Ir„I PF ToR,
<br /> . Please typo or print clearly tr,li requested inforrriatitqkn.
<br /> . Use a hard point writing instrument,you are'makind 2 copies:a ,�
<br /> , Tank owners most submit a plea plan to the local agency showing the location of the LS Ts with respect
<br /> to buildings and landmarks(271 t (a)( )CCR],
<br /> o Tank oiriers miust gubmit documentation showing compliance with state financial responsibility require-
<br /> ments lathe local agency for petroleum USTs(271 (a)(1 1) ],
<br /> TCP OF FORM: MARK ONLY ONE ITEM
<br /> t Clark an (X) 9n the no nexi to the kern that beat describes the reason the form is being completed,
<br /> 2. Indicate the DBA or Facility nave where the tank is petalled,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL ITEM - IF UNKNOWN m SO SPECIFY
<br /> A. Indicate ownerstank k Ise A If there Is a taro number that is used by the owner to,identify the tank(ex,
<br /> AF7Cr7F ),
<br /> Indicate the na of the tai€z p;t v .hat „ !rn- acture the tank( a E TANK,MFG),
<br /> MFG).
<br /> Indicate the year the tank wasInstals d (ex. 1987). �
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).
<br /> IL TANK CONTENTS
<br /> A, t. IF MOTOR VEHICLE Iaf,bL,, check box 1 and complete items B&C.
<br /> 2, If not mo,rOR VEHlCLE f LIEL,c€ ec,the appropriate boar in section A and complete items B&U.
<br /> Fa, Check the appropd atf�cox.
<br /> Check the tyre of 3 t rOr Vti H!Ci_E FUEL Eof box t is checked in
<br /> Print the chemical r an-',r of the hazardous substance stored in the tank and the C.A. . , (Chemical
<br /> Abstract Service number),), t box l is NK',iTcheckedin A.
<br /> Ills TANK CONSTRUCTION-MARK ONE TEM ONLY IN BOX A, B,
<br /> t. Check only one item in TYPE OF SYSTEM,,M,,TANK MATERIAL, INTERIOR LINING and CORROSION,
<br /> PROTECTION,
<br /> 20 If OTHER, print in the space provided,
<br /> k,
<br /> I, PIPING INFORMATION
<br /> t, Circle"A"9 yr of ove ground circle i"9 Ire underground,and circle doth if applicable.
<br /> 2. If UNKNOWNr..l .or if OTHER, pi t in, space provided,
<br /> 3, Indicate as"fie L...A ".E l”C,I ON .aysgev , used to comply with the monitoring requirement for the piping.
<br /> , TANK LEAK DETE Cvr r
<br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring;requirements for the tank,,
<br /> V1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> t. ESTIMATED DATE LAST USED- MONTHNEAR (January, 1988 or01/88)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the,tank(in Gallons).
<br /> , WAS TANK FELLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> TANK OWNERAUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED AmTE (see section 2711 (a)(13) CSC R)
<br /> fINSTRUCTION FOR THE 1F.CeTCAL AGENCIIFES
<br /> "'he state underground storage tank identification number is composed of the two digit county number,the three digit
<br /> jurisdiction number,the six digit facility n rnber 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 number rust be the erne as
<br /> shown 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. It the local agency prefers the Mate Board to design the tank number, please leave it blank.
<br /> T I2 THE RESPONSIBILITY OF THE &.00A AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACC U-
<br /> ',,C F THE INFORMATION.�.ION. TRIP LOCAL. ,�T�iC I RESPONSIBLE FOR TIFFCOMPLETION OF THE
<br /> "LOCAGEPC UST. `u�o L s 1FORM ,ION BOX, TIE. CAI AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK �,-_'O'Y SHOULD BE RETAINED Y TIFF TANK OWN R,
<br />
|