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INSTRUCTIONS FOR PLS WM OBN
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16, California Code of Regulations and sections 25286,25287,and 25289
<br /> f Chapter,5.7,Division 20, health and Safety Code require tank owners to apply for an LIST operating permit.
<br /> 1.' One FOR "B"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES,
<br /> REMOV-
<br /> ALS and/or any other TANK INFORMATION HAf n
<br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND
<br /> Please type or print clearly all requested information.
<br /> ation.
<br /> . Use a hard point writing instrument,you are.making 3 copies.
<br /> 5.' Tank owners mast submit a plot plan to the local agency showing the location of the LJ T"s with respect
<br /> to buildings and landmarks 12711 (a ( CCT/],
<br /> 5, Tank yawners must submit documentation showing compliance with state financial responsibility require-
<br /> menti
<br /> q ire-
<br /> ment to the local agency for petroleum USTs(2711 (a)(1 1)CCRJ,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1.' Mark an ( in the box next to the item that best describes the reason the form is being completed.
<br /> 2.' Indicate the DBA Facility name where the tank is installed,
<br /> 1. TANK DESCRIPTION - COMPLETE ALL TT - IF UNKNOWN - SO SPECIFY
<br /> A Indicate owners tank I -If there is a+tank number that is used by the owner to identify the tank(ex.
<br /> A7g75g
<br /> Indicate the name of the'company that manufactured the tank(ex,ACME TANK MFG),
<br /> C. Indicate the year the tank was installed (ex, 1987).
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000etc.).
<br /> I. TANK CONTENTS
<br /> 1. IF MOTOR VEHICLE FUEL,cheek box 1 and complete items B&0.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D,
<br /> B. Check the appropriate box.
<br /> , Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in Atm
<br /> D. Print the chemical name of the hazardous substance stared in the tank and the C.A.S. , (Chemical
<br /> .Abstract Service number),if box 1 is NOT checked in A.
<br /> Ili. ' TANK TU TI l - MARK ONE ITEM ONLY IN BOX A, B,
<br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INT I INING and CORROSION
<br /> PROTECTION.
<br /> 2.' If OTHER,'print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> 1.' Circle"A"if above ground circle"IJ"if underground,and circle both it applicable.
<br /> 2, If UNKNOWN circle;or if OTHER, print in space provided.
<br /> .i Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping.
<br /> TANK LEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION syster•n( used to comply with the monitoring';requirements for the tank,
<br /> 1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, EST'IMAT'ED DATE LAST USED-MONTHNEAR(January, 1958 or 01/88),
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> . WAS TANK FILLED WITH INERT MATERIAL?IAL Check"Yes"or"Nola
<br /> TANK OWNER OR AUTHORIZED ;REPRESENT"AT"IVE' UST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 ( OCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification n number is composed of the two digit county number,the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank numbers The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(915) 7-4302, The facility number must be the same as
<br /> shown in form�A". The tank number may be assigned by the local agency,however,this number roust be numerical and
<br /> knot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank,
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE IL11-Y TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION, T HE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE NLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER
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