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INSTRUCTIONS FOR COMPLETING FORM :'P,,
<br /> GENERAL INSTRUCT ONS:
<br /> 1, One FO shall be completed for each tank for all NEN PERMITS, PERMIT CHANGES, REMOVALS and/or~ any
<br /> other TANK INFORMATION CHANGE.
<br /> 2 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR,
<br /> • Please ��pe or
<br /> print clearly
<br /> r' sl requested information.
<br /> 4 Use a hard point, writing instrument. you are mating 3 copies.
<br /> TOP OF FORM: 'NARK ONLY ONE ITE11„
<br /> 1. Mark an ',X) n the box next to the item that best describes the reason the form is being completed.
<br /> €. Indicate`.the DBA or Facility na'T)'c va=3;ere the tank is installed.
<br /> 1 , TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A, indicate owners tank 1D # - If there is a tank number that is used by the ;owner to identify tt e tare
<br /> (ex. AB70789).
<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. {SBI).
<br /> D. indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.)
<br /> II, TANK CONTENTS
<br /> A 1 . IF MOTOR VEHICLE
<br /> .l.:,LE f U ( , cher' box and complete items B & C. d
<br /> �:k 1. n�, ,arh:l
<br /> 1. 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 ;t MOTOR VEHICLE FUEL (if box 1 is checked in A).
<br /> D. Print t:liEe chemical name of the hazardous substance stored in the tank and the C.A.SJ (Chemical
<br /> Abstract Service number). if box t is NOT checked in A,
<br /> III. TANK CONSTRUCTION - ARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1. ., e_K only one item
<br /> a ,, irTYPE J_ CYS_r _". TANK MATERIAL, iPiEliR LINING an: CORROSION PROTECTION.
<br /> 2. .f ..,.. El', print in the space provided,
<br /> It PIPING INFORMATION
<br /> 1.
<br /> ,
<br /> Circle above E' ., : , underground, and circle both i applicable.
<br /> .j �I! �.. K 64 C',^��'� ,,y,{.'1 a:, �or, i ¢ OTHER, pri"i t i n ;a.l.
<br /> ... indicate the LEAK DETECTION .;r..t_::'r',s1 lh_,,.0 to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> 1. intricate the LEAK DETECTION system(s) usedto 'amrlj with the monitoring requirements forthe tank.
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED I.G Ds"1TL LAST i.?„>E..D MONTH/YEAR (January. 1988 or 01/88)
<br /> 2. ESTIMATED Ei31ANTITi' of HAZARDOUS Rr A,( i ung in the to (in Gallons),
<br /> 3. WAS TANK FI_
<br /> 1; D WITH INERT MATERIAL? Check 'Yes' or ,NO.
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage
<br /> st t ge t nidentification number iscomposed of the two digit county rL
<br /> f?ei the
<br /> ethree
<br /> digit jurisdictionr ?berthe six digit facility number and the six digit tank number. The county and
<br /> jurisdiction
<br /> numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The
<br /> facility number rust be the same as shown inform , T'A,' he tank number may be assigned by s<te local agency.
<br /> ,
<br /> however,f, �h l °iiiT?e ;t,
<br /> mu numerical an cannot contain an alphabet, I i the local aCgen yprefersh Stat:e
<br /> k
<br /> Board to assign the tank number. pleas; leave it blank. thy,
<br /> State
<br /> IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE (ONLY” INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM "A' AND ASSOCIATED FORM 'BR(s) TO THE FOLLOWING ADDRESS.
<br />
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