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INSTRUCTIONS FOR CIO Lr _1FI1Nk: T"O `B" 0
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<br />GENERAL INSTRIr C1FIONS
<br />Section 2711 of Title 23, Division 3, Chapter 15, California Code of Regulations and sections 25286, 25237, and 25289
<br />of Chapter 5.7, Division 23, Ho_ ltr'la 1d , ,f , ( ode rw:,�cluire tank owners to apply for an LIST operatingpermit,
<br />1, One FORM "E .,I �alll be ed for each tank for all NEW PEt I € S , PERMIT CHAN E ,IE -MOV -
<br />ALS and/or any other TANK INFORMATION CHANGE,
<br />2. This form shou ", be bv either the PERMIT APPLICANT or the LOCAL AGENCY UNDE -
<br />3. Please type or print clearly a9 requeszdinformation.
<br />4. Use a hard point writing instrument, you aro. making 3 copies.
<br />5. Tank owners must submit a plot plant to the local agency showing the location of the USTs with respect
<br />o buildlings and landmarks f27=1 (a)(5) CCS_].
<br />5, Tank owners must submit documentation showing compliance with state financial responsibility require-
<br />ments to the local agency for petroleum LISTS [2711 (a)(11) COP).
<br />TOP OF FORM: MARK ONLY ONE ITEM
<br />1. Mark an O in the box next to the Item that best describes the reason the form is Feeing completed.
<br />2. indicate the DBA or Facility name where the tank is installed.
<br />TANK DESCRIPTION M COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br />A. Indicate owners tank ID # a If there is a tank number that is used by the owner to Identity the tank (ex.
<br />AB707891/1
<br />Indicate the rar- the d=rrny th; man?ga
<br />ctred the tan=k ;ex. ACBE TANK MFG' -
<br />C. Indicate the year the tank was installed (ex. 1987 ),
<br />D. Indicate the tank capacity in gallons (ex. 25,050 or 15,00 etc,),
<br />If. TANK CONTENTS
<br />A. 1, IF MOTOR VEHICLE FUEL, check box 1 and complete items E & C.
<br />2. If not MOTOR VEHICLE
<br />FLIEL, or r.k the appropriate box in section A and cornpiete items R & D.
<br />6, Check the appropriate box.
<br />C. Check the type of MOTOR 'EI' ICL E FUEL (if box 1 is checked in A).
<br />D. Fruit the chemical name of the haaardoua substance stored In the tank and the C.A.S. . (Chemical
<br />Abstract Service nur ber), if box 1 is NOT checked in A.
<br />Ill. TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX A, Rg C & D
<br />1,, Check only one iters in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION
<br />PROTECTION,
<br />2, If OTHER, print in the space provided.,
<br />IST. PIPING INFORMATION
<br />1. Circle "A" if above ground circle "U" if underground, and circle both if applicable.
<br />2. If UNKNOWN circle; or if OTHER, print in space provided.
<br />3. Indicate the LEAK DETECTION system (s) used to comply with the monitoring requirement for the piping.
<br />. TANK LEAK DETECTION
<br />ION
<br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank.
<br />I. INFORMATION ON TANK PERMANENTLY TLY CLOSED lel PLACE
<br />1. ESTIMATED DATE LAST USED
<br />. MONTH/YEAR (January, 1988 or 01188)
<br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tante (in Gallons).
<br />3. WAS TANK FILLED WITH INERT MATERIAL'S Check "Yes" or "o".
<br />TANK OWNER OR AUTHORIZED
<br />I-"ORIZED REPREE'SEE TATIy�rE MUST SICK AND DATE THE FORD AS IND -
<br />CATED "see section 2711 (a 1 ) CC
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<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The state underground storage tank identification 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 number. The county and j risdiction numbers are
<br />predetermined and can be obtained by calling the State Board (915) 227-4333. The facility number must be the sante as
<br />shown in form. ` " -a he tank number may ? b s t"ecl by the local agency, however,, this number Must be numerical and
<br />c a%ns arra `.,,unt„,rt an aiEa tab,;,', ;x,., li'tre' loca! au e ¢ b refR` rs xr;e Store Board to assign the tank number, please leave it blank.
<br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY TI AT `INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br />RACY OF .TETE INFORMATION, THE LOCAL AGE CY IS RESPONSI LE FOR THE CO€ PLETIO t OF THE
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<br />"LOCAL AGENCY USE ONLY" INFORMATION BOX, TIME LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br />YELLOW COPIES, THE PINK COSHOULD BE RETAINED BY THE TANK NEB.
<br />t.
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