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INSTRUCTIONS FOR COMPLOING FORM "R,£
<br /> GENERAL INSTRUCTIONS ;
<br /> Section 2711 of Title 23, Division 2, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety erode require tank owners to apply for an LIST operating permit, ,
<br /> 1. One FORM "R` hall be co oleted for each tank for all NEW PERMITS, HERMIT"CHANGES, RFM V_
<br /> ALS and/or any other TAINS INFORMATION HANG .
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> 3. Please type or print clearly all requested info m aton.
<br /> 4. Use a hard point writing instrument,you are making 2 copses.
<br /> . Tank owners must submit a plot plass to the local agency showin the location of the USTs with respect
<br /> to buildings and landmarks (2711 (a)(8)CCRII.
<br /> . Tank owners roust submit documentation showing compliance.with state financial responsibility require-
<br /> ments to the local agency for petroleum LTC T s (2711 (a)(11) CGRj,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1, Mark an (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 is installed,
<br /> I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN 1 - SO SPECIFY
<br /> A. Indicate owners tank ID #m If there is a tank number that Is used by the owner to identify the tank(ex.
<br /> A1707 ).
<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 (_ex, 1287).
<br /> D, Indicate the tank capacity in gallons (ex.25,000 or 1 C OO etc.).
<br /> it. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items R&C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in sections A and complete hennas 6&De
<br /> B. Check the appropriate boar.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored Fn the4 nk and the C.A,S.#, (Chemical
<br /> Abstract Service number), if box 1 is NOT checked in A.
<br /> III. TANK CONSTRUCTION « MARK ONE ITEM ONLY IN BOX A, B, C & I
<br /> 1. Check only one items in TYRE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. if OTHER,, print in the space provided.
<br /> ISI. PIPING INFORMATION
<br /> 1. Circle"A" if above ground circle,BCF if underground, and circle both if applicable,
<br /> 2. If UNKNOWN circle; or if OTHER, print in space provided.
<br /> 2. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V° TANK LEAD DETECTION
<br /> 1. Indicate the LE [DETECTION systems used to comply with the monitoring requirements for the tank,
<br /> SII, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED TF LAST USED-,MONTH/YEAR (January, 1982 or 011813)
<br /> . ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> . WAS TANK FILLED WITH INERT MATERIAL? Check"Yes" or"No".
<br /> TANK OWNER OR AUTHORIZED ED REPRF FNTATI MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED
<br /> N I-CATH T [see section 2711 (a)(13) CCR)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES.The stage underground storage tank identifications number Is composed of the two digit county number, the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tarok number. The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the Mate Board(916)227-4203, The facility number must be the same as
<br /> shown in fours "A°. The tank number- py e assigned b the local agency,however,t €s number must be numerical and
<br /> cannot contain an alphabet, If the to l agency prefers1the Mate Board to assign the tank number, please leave It blank.
<br /> 1T I2 THE RESPONSIBILITY OF THE LOCAL AGEINCY THAT INSPECTS T HE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION, TFIF LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION TIC:N CF THE
<br /> "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. TGIF PINK CORY SHOULD BE RETAINED BY TGIF TANK OWNER.
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