COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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INSTRUCTIONS F 7 COMPLETING FORM o, . GENERAL INSTRUCTIONS Section 2711 of Title 23; Division 3, Chapter 16, California Code of Regulations and sections 26266, 25287, and 25239 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST operating permit. 1. One FOR/ "D"shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMQV-. ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR, 3. Please type or print clearly all requested information. 4. Use a hard paint writing instrument,you are making 3 copies. 6. Tank owners must submit a plot plan to the local agency shoring the location of the LFTs with respect to buildings and landmarks[2711 (a)(3) CCR[, 6. Tank owners must submit,documentation showing compliance with state financial responsibility require- ments to the local agency for petroleum LISTS [271 i (a)(11) CCPD. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describes the reason the farm is being completed, 2. Indicate the DESA or Facility name where the tank is installed. I. TANK DESCRIPTION IO - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID#m If there is'a tank number that is used by the owner to identify the tank (ex. AR7C1769). D. Indicate the name of the company that manufactured the tank(ear.ACME TANK MFG), C. Indicate the year the tank was installed(ex. 1967). D. Indicate the tank capacity in gallons (ex.25,000 or 19,000 etc,). II. TAIL CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B& C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items S&D. D, Check the appropriate box, C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A)= D. forint the chemical name of the hazardous substance stored in the'tank and the C.A.S. . (Chemical Abstract Service number),If box 1 is NOT checked in A. Ill. TANK CONSTRUCTION RUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D 1 - Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, . If OTHER, print in the space provided. 1 . PIPING INFORMATION ATION 1_ Circle "IIA"if above ground circle "C" if underground, and circle both if applicable. 2. If UNKNOWN"circle; or if OTHER, print in space provided. 3. Indicate the LEAD DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAD DETECTION 1. Indicate the LEAK DETECTION system(s)used to coma lywith the monitoring requirements for the t=ank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED w'C OI THIYEAI (January, 1988 or 01/83) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST. SIGN AND GATE THE FORM AS IN i-,. CATED [see section 2711 (a)(13) CCRJ INSTRUCTION FOR THE LOCAL AGENCIES The state underrground storage tank identification number is composed of the two digit county number,the three digit jurisdictionumber,'the six digit facility number and the six digit tank number. The county and`j ri diction numbers are predetermined and can be obtained by.calling the State Board (916)227-4303. The facility number mist be the same as shown in form "A The tank number may be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR TIME COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFO ATION BOX. THE LOCAL AGENCY SHORETAINTHS Ct 11Gli AL AND YELLOW COPIES. THE Pit C HOULD BE RETAILED 3Y THE TANK ER.