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INSTRUCTIONS FOR OMi: -TING FORM €,R„
<br /> NERAL INST€R:LfSTIONS
<br /> Section 2711 of Title 23, Division 3, Chart,. r 1 . California Code of Regulations ars sections 25286, 25287. and 25289
<br /> of Chapter 3.7, Division 0 Hl, o...hl Scan`-, "'ode require tank owners to aL, �y for an LIST operating permit,
<br /> 1. One FC7 rM "B` shall be ccrnp'eted for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 2. This form should be completed by either the PERMIT APPLICANT"or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> 3. Please type or print cl arly all equoated information.
<br /> 4, Use a hard p=oet writing inSIrr,M nt, you are rriaking 3 copies,
<br /> 2. Tank owners must submit a. plot plan to the local agency showing the location of the LSTs with respect
<br /> to buildings and landmarks(2711 (a)(3)SCR],
<br /> 6, Tank owners must submit documentation showing compliance with Mato financial responsibility reguire-
<br /> I tints to the local agency for petroleum USTT[2711 (a)(11)C CRL
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark ars (X) in the box next to.the stern that best describes the reason the form is being completed."
<br /> 2. Indicate the SEA or Facility name where the tank°is installed,
<br /> TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN ., SCS SPECIFY
<br /> A. Indicate owners tare ID If there is a tank number that Is used by the owner to Identify the tare(e ;
<br /> AB70733).
<br /> S" Indicate the name of the company that manufactured the tank:(ex.ACME TANKMFG), ,
<br /> S, Indicate the year the tank was installed (ex, 1237),
<br /> I"..1. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc,)
<br /> I. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items E&C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D.
<br /> R. Check the appropriate box.
<br /> CT. {heck the type of MOTOR VEHICLE FUEL(if box 1 is checked In A),
<br /> . Print the chemical name of the hazardous substance stored in the teak and the C. ,.S.ff, (Chemical
<br /> Abstract Service number),if box 1 Is`NOT checked in A,
<br /> Ill. TANK CONSTRUCTION'- MARK ONE ITEM ONLY IN BOX A, R, C & D
<br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2. If OTHER, print in the space provided.
<br /> 1v. PIPING INFORMATION
<br /> 1. Circle"A,€ if above ground circle"U"if underground, and circleboth 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 /> V. TANK LEAK DETECTION
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank,
<br /> 1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMATED DATE LAST USED-_ MONTH EAR (January, 1388 or 31/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the flank (in Gallons),
<br /> 3. WAS TANK FILLED WITH INERT"MATERIAL? Check"Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENT'ATI E MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a)(13) COR
<br /> INSTRUCTION FOR THE LOCAL. AGENCIES
<br /> The state Underground storage tank€^,en"fication number is composed of the two digit county number,r, the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank number. The.dounty and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the Mate Board(9,13)227-4303" 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 must be numerical and
<br /> cannot 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 FACILITY TO VERIFY THE AC CLI-
<br /> RAC YCSF THE INFORMATION. THE LOCAL A(t,E C`� IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE€aNLY°l INFCTRMA' ON BOX, THE LOCAL AGENCY SHOULD RETAIN €HE ORIGINAL AND
<br /> YELLOW COPIES. THE PINK COPY SHOULD RP RETAINED BY THE TANK_ OWNER.
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