|
IIUS't'RUCTIONS FOR COMPLETI R
<br /> NG FO M. B
<br /> _1.
<br /> ERAL INSTR3TIC3NS
<br /> n X711 of Title 23, Division 3,Chap"ter 16 6411fornia Cod ''df lationigland X286,25287,and ,—RW
<br /> , sf Chapter 6.7,Division 20, Health and Safety Cod
<br /> 34quire tank--dwhers to apply for an UST operating permit. _ s
<br /> m1. a 1=0RitiT"'B"shal,I be mpfeted,for eacl tank for PERMIT PERMIT C iAl+1 S,'REMOV,
<br /> ALS a tiror an other Tk K IN
<br /> fo ' 'hoaFC}RNfATiON CHAN i,, _
<br /> ,.
<br /> _ s
<br /> w l2;`.a Thlsl c" pl ted by�ither the PERMIT AP C' AI T or the L&A,.AGENCY UNDER`-
<br /> GROUND TA INSI TOR.
<br /> 3Please type-or print,cleady,all requested Information.
<br /> 4. Use a hard point writing instrument, you ara,maki g 3 copies ,.� rx .. .�.. � ..� a
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with,respect-
<br /> to buildings grid landmarks[2711 (a)(8)OCR],
<br /> 6. TankQvd*ts rtmust submit documentation showing complianci'with state°financial responsibility require= �-
<br /> ---ments to thelocal'agency for petroleum USTs[27-f'I (a)(1 t"Y CSR
<br /> TOP OWSM4. MARK ONLY ONE ITEM
<br /> 1 Mark,an (X)in the box next to the item th t best ` s.th form Isb0ng,pb
<br /> 2 k°Indicate the DBA or Facility name Mrle ta6ik*
<br /> t:r 1. , SCRIPTION COMPLETE ALL ITEMS -;IP':,UNKNOWN SO IFYIw
<br /> A. Indicate owners tank ID#-if there is stank number that is used by the ownero Identity the tank(ex:
<br /> AB70789).
<br /> a Indicate the Mme of the company that mOufact tired the tank(ex ACME TANK
<br /> C. Indicate the` ear the tank was installed eic. 198?. , a-
<br /> D. - Indicate the tank capacity in gallons(ex.28,000 or 10,000etc.).
<br /> 11. 'TANK CONTENTS r
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items B&C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriatebox in sectlortA.and compl4items b&b-
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked ism A).
<br /> _.D. Print the chemical name of the haAfd'ous-substance*ibd in the tank and the'C.A.SAA, emical ,
<br /> Abstract Service number),if box 1]s NOT checked'in A: i
<br /> 111. TANK CONSTRUCTION-MARS 6NE"If- EM ONLY IN BOO A, B C &
<br /> 1.. Check only one`Item in FE t)F SYSTEM TAt�IC MAT TI�BL{ nd :ORiQSION
<br /> PROTECTION. ... :. _,, .,{ - .;�
<br /> If OTHER,print in the spaC rovidfed `"
<br /> IV. PIPING INFORMATION
<br /> ,.
<br /> cle A"i#above groan " �tddrground, rd circle boat applicable.
<br /> 2. NKNOWht circle;or ,��in space pravided,
<br /> 3. Indicate the LEAK DETECT16N s em(. )
<br /> s used 10,pompiy with the monit(ring requirement =piping. ,
<br /> y ,
<br /> V. TANK LEAK DETECTION Win:
<br /> 1. Indlcate 66 LEAV ETECTION systems dsed to comply with the monitoring requirement for<the t k.
<br /> VI. INFORMATION ON TANK.PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED- MONTHIYEAR(January,1988 of 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL?'Check"Yes`or"No".
<br /> TANK-OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND.DATE SHE, ORM, t@l !-
<br /> CATED (see section 2711 (a)(13) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification.cumber Is posed of the tWo-digit county number,the'three digit
<br /> jurisdiction number,the six digit facility number andthe six digit number . The county and jurisdiction numbers are
<br /> predetermined and can.be obtained by calling the State Board(916)227-4303, TIS 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 must be numerical and
<br /> cannot contain an alpfiaoef. 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 T AT II ,SP CTS THE FACILITY TO VERIFY THE A CUJ V:
<br /> RACY OF THE INFORM
<br /> .= E LOCAL AGENCY I AS,; FOR THE OVfPLETION QF
<br /> "LOCAL AGENQY USE ONLY" RMATION 60x. THE. LOCAL A, . Y S l 3ETAIN AtVp
<br /> ili
<br /> YELLOW'COPIES TI IE:.piN C St10UL0 l E RE'CAINED:HY,RI€ `{'AN NER
<br /> ^ >F
<br /> � 1_� rte-
<br />
|