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INSTRUCTIONS IFOR COMP'LE'TIFING FORM
<br /> GENERAL INSTRUCTIONS
<br /> Section 27,11 of Titie 23, Div��,;io,,n 6', ornia 1-odeof Re-,
<br /> ,.ulafions and sectioris C26 , 25,287, and 25289
<br /> o a F'operating permit,
<br /> of Chants,-t57, 20k� u nk ownei t pply for an US
<br /> One FORM `6 (,,-,orrpieted fi_�. eac.4h, ianktor ail NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS arida or any other TAl,iK iNFOIRIrA' ICN CHANGE.
<br /> 2� This fornn should be cornpleted t"v th�e PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK iNSPEGTOF11,
<br /> 3, Please P,inat requr,,��id Inf(crn ftfion,
<br /> 4, 'Jae a hard ani rnaknj3, copies,
<br /> Tark own,,,�Ts aj,,,Jo,1,1 o th.e !ocal aciency showing the location of the LISTs with respect
<br /> ,U) buildings am,,A', I
<br /> 6 TankcMvn,,,,.rs n;ul,st stibnnit D",-,"Mpliancewitin,state.finaneiai responsibility require-
<br /> me-it's"o the icca� age�,n'cy fe_"� petroj�, 'n q- `271 a)(i 11) CGRI,
<br /> TOP OF FORM: MARK ONLY Of,1JE iTEM
<br /> Mark an (X) in the box next tothe ite ',", that best des,.c6bes the reason the form is being completed,
<br /> 2, Indicate-the DBA ear Faciiity n,'�,tne where,the tank is installed,
<br /> I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A� indicate owners tank I D 14,- §i'hert? is a tank, nunbezr that is used by the owner to identify the tank(ex,
<br /> AB7,08C-11
<br /> 13, ln6cat,181 he name olth�.,,,con"'r-ii-"vny 1111e"R rna n 1.4,1 actij red the tank fee. Ar,METANK MFG),
<br /> irs ,,d iex, 19,!,337),
<br /> C,
<br /> D, IndcaTc,,,the tank carjacity".n 25,0s.., or 10.000 etc,),
<br /> if, TANK CONTEENF!"S
<br /> A. 1, IF MOi'OR, VEHICil-E iu,,ox 1 and comPlete tt'E'Ims B& C,
<br /> 2, if no?M9T,,'_')R VEH f"I(AC-11"i �ihOC�k fl:e approp,,late box in section A and co,.,,,T1 plate items B&D
<br /> B, Cheer,*the appropdate box_
<br /> ,�,` I ri V
<br /> C, Check Ithe t)qp- oi W`Y�,"' ''E"WE' FIJEL (if box 'I is checked in A).
<br /> DPrint the chelnica� iCIrrie` 0i III h2za�,dous substance stored in thle-tank and the C.A,S.#, i'Chennical
<br /> Abstract Service number'), if box 1 is NOT checked in A.
<br /> Ill, TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> _ Check only one item 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 /> 1Circle"A" if above ground circle"U" if underground, and circle-both if applicable,
<br /> 4- If UNKNOWN circle; or if OTHER, print in space provided.
<br /> 3, Ii f ;Care-he LI-,AK SV�,1,1`,-,1n-q1s) used to cornply with the monitoring rf-N:iurrementfor the piping,
<br /> 1Idicare,the
<br /> (a", t,ised'm complyv-Jith the monitoring reqUirements,fb,T,the tank,
<br /> VL INFORMATION ON TANK PERMANENTLY ;LU— Cl OS�5ED
<br /> r_ IN PLACE
<br /> 1, ES'DMATED DA,Tir"_- (January, 1988 or01/88)
<br /> 2, ES1 WATED OUANT117'Vcif HA4Ri')0US SUISSTANCE remaining in the tank(in Gallons),
<br /> 11 1 ,
<br /> 3, WAS TANIK FILLED WITH Check "Yes or"No".
<br /> TANK OWNER OR AUTFiC?R]ZED MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED `see section 2711 (a)(1,3) `CFi)
<br /> INSTRUCTION FOR T FiE LOCAL,
<br /> The state undergrowid storage took idsntificatio�n, nuunniner is comi-,osed of the two digit county number, J!ie three digit
<br /> jurisdiction nuirnber,the six digit facia11'11oarnlbel and the,sixdi
<br /> lgif,tank pqrnber. The county and jurisdiction nunn.bQrimer
<br /> e
<br /> predetecmined and c-an be by calling Tie"3"mate, 227-4303. Thefacility numberniust bethe same as
<br /> sho)wn in,forin "A", Thetank E"Umborzyiay oeassigned by the iocal agency,however, this,nurnber mustbe numerical and
<br /> a thle State Board to assign,the tank numbsr, please leave it bi'ank.
<br /> ESP,
<br /> U� Y rl- L THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> 'IT IS "f'H'_, tRE_ _,NS16fl THE i OC AL AG=NC.,Y ,
<br /> RACY ()F THE ,iNFC_)RMAT ION, THE L0,,,,'_',AL AGENCY �S 'RUESPONSIBLE FOR THE COMIPLETION OF THE
<br /> '"U"ICAL AGEN-C"Y U-SE QNJLY� iNF-'0RIaA`-!0N BOX, HE: OCA SHOULD RET'MN THE ORIGINAL AND
<br /> YIELLOW COPIES, -1`1-iE PINK SHOULD BE RETAIfNED,BY T HE,TAN sERI
<br />
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