|
INSTRUCTIONS FOR COMPLETING FORM "
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 Vr Title 23, division 3, Chapter 16, C a1, o:niat Code,,a € Rac.ul ation i and sections 25286, x728 , atnd 2528-9
<br /> of Chapt . 6,7, Division 20, Health and Safety Code,E wire'tank owners to apply for an LIST operating permit,
<br /> O
<br /> ne FORM "B shall be COMpl ted fn. each tank,for al NEW PERM
<br /> PERMIT � fi �; � ? �� w
<br /> ALSand/or any other TANK ',NFOR'' T ION CHANGE,
<br /> tt
<br /> n This form should bcompleted by c er the PE 'EMIT APPLICANT- r the LOCAL AGENCY UNDE -
<br /> GROUN TANK S P $ Tt
<br /> , Please type or onnt;clearly all : .lu sd infor f ation,
<br /> 4. Use a hard point writing r, strUrn6nt, l.F are making 3 copies.
<br /> ank owners?past ah'c`hr-nit a pict planm the" loc al agency showing the location of the USTs with respect
<br /> to buildings cit"fid f andm.arks r2 1 1 (ca)(8)CC i,
<br /> 6, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ment's
<br /> ire-ra nts t€o the local agencyfor petroleum U Ts (2711 (a)(1 1) CCRI.
<br /> F OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark on (X) In the box next to-the item that bolt describes th= reason the form is being completed,
<br /> , 1ndif,at. _ ,._ C',Ek � ll..C a Installed,
<br /> ;,,
<br /> €
<br /> 1. TANK DESC"RIPT l%..?N COMPLEETE ALL €€-..,:, _ IF UNKNOWN€N - SO SPECIFY
<br /> A, Indicate owners,,,rs trank Ire '. - I ..,�,«. 'sa.'.i.,t «i€ F,a,,.� ae i used�as °"the tai C to identify the t x,
<br /> Via, Indicate the name of the company that manufactured th tank(ox, "CE TANK MFG),
<br /> C. Indicate the year the tank was installed (ex, 1987),
<br /> , Indicate the tank capacity in gallons (ox.25,000 or-1 0,000 etc.).
<br /> Il. TANK CONTENTS
<br /> A. 1. IF MOTOR VHltCLE FUEL check bo 1 and c pl to Items PPS& C.
<br /> if not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&U.
<br /> B. Check the appropriate box,
<br /> , Chock the typo of MOTOR VEHICLE FUEL(if box 1 is chocked in A).
<br /> U. Print the chemical name of the hazardous s bst nce stored in the-tank and the .A. .#f. (Chemical
<br /> Abstract Service number),r), if box 1 is NOT chocked in A.
<br /> III, TAINS CONSTRUCTION7-MARK ONE ITEM ONLY IN BOX A, 6,
<br /> _1. Che.k only one item in TYPE OF SYSTEM,TANK i MATERIAL, INTERIOR LINING and CORROSION
<br /> _-PRO T FtCTI -
<br /> , If OTHER, print in the space provided.
<br /> IV, PIPING INFORMATION
<br /> ISI -�
<br /> 1, Circle"A" if above ground circle "U"if underground, and circle-both if applicable.
<br /> , If UNKNOWN circle; or if OTHER, print in space provided.
<br /> . Indicate the,LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V
<br /> T ANK LEAK DETECTION
<br /> Indicate the LEAK TETE TIOI system(s )used to comply with the monitoring requirements for the tank.
<br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED:.I ONTH/Y F (January, 1988 or 01/t3 )
<br /> , ESTIMATED QUANTITY of HAZARDOUS U fa T AES remaining inin in the tank (in Gallons),
<br /> a WAS TAMS FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER AUTHORIZED FF E NTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED
<br /> I-CATER (see section 2711 ( )(1 31 GR)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The stone underground storage tank Identification number is composed of the two digit county nu mber,,,the throe digit
<br /> rarisdictioo number,the raiz digit facility number and the six-digit.taLok number, The county and jurisdiction r umb rs arcs
<br /> predetermined and can be obtained by calling the State Board(9,16)227-4303, The facility number must be the same as
<br /> shown in form "A". 'The tarok number may be assigned by'i the lrfc l agency,however, this number must be numerical an
<br /> cannot contain an alphabet, If the local agency prefers the State Board to assign the tarok number, please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY Y TE AT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY
<br /> U-
<br /> RA Y OF THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY UFFONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD FETA€ESI THE ORIGINAL AND
<br /> YYELLOWYELLOW � FIF
<br /> COPIES, THE �I �,.: 3 LULU F RETAINED Y THE,TAI l ER,
<br /> °
<br />
|