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IITPfTTIi FOR COMPLETING FORM
<br /> L IiT iI IST
<br /> $e0' 2711 of Title ,Division 3,Chapter 16,Califomia Code of Regulations and sections 26266,25267, and 25259
<br /> ofpt r 6.7,'Division 4 Health and Safety Code require't h6*ndrp to apple ibr ars LAST operating p rtnit.
<br /> 1 a One FORM't" lull be completed for a n tank iur, li NFA PFP IT , PERMIT i A F REMOV
<br /> ALS arid/or any other TANK I F P ATt N HANGE ,
<br /> This fc held b mplet d either the PERMIT PLI T r th,
<br /> ie,LOCALAGE €DER�
<br /> GROUND TANK INSPECTOR.
<br /> . Please type or print clearly all requested inf rmation.,
<br /> . Use,a hard point writing instrument,you are rn kir g i ; "
<br /> 6. ,Tank roc must submit plot plan t the'local agency hawing the location of the USTs with,tesJ)a t
<br /> t6 building's and landmarks[2711 ( )( ) PI.
<br /> . Tank owners must submit documentation showing,compliance With staid fln n . ,rep,�...,diilt require-
<br /> ments
<br /> q it -
<br /> nt to the Id (agency for petroleum USTs(271 1 t )(1 I)CCRI.
<br /> F F LY ONE ITEM
<br /> ,,...;
<br /> 1-, Mar �(X),,In,the box next to the:item that best describes rosop the form is
<br /> Indicate t1 A or Facility rlarravir the tnit i intlld.
<br /> I. TANK DESCRIPTIONPL ITEMS �, I
<br /> A. Indicate owners tank I -If there is a tank number thitIs,u$6dby, 1h4ownsrto
<br /> AB70783).
<br /> Indicate the n of the company that an fs r d t k( . T�A I� ;
<br /> C. Indicate the yeartank was installed(ex. 1 7).
<br /> D. Indicate tank capacity in gallons(ex.2t,000 or^10,000 etc.).
<br /> 11. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete item .
<br /> If not MOTOR VEHICLE FUEL,check the appropriate bdk.ln etibn A and complete it s 8&D.
<br /> B. Check the appropriate box.
<br /> C. Check of MOTOR VEHICLEL(if box 1 is checked in ).
<br /> D. Print the chemical name of the hazardous substance stored in the,tank and the :A4 . ,(ChaniCal
<br /> Abstract Service number),if box I-is NOT checked in A.
<br /> III. TANK CONSTRUCTION- MARK ISI ITEM ONLY ]NAl, ,Bt
<br /> 1. Check only one item in P T" TANK`.MATERIAL,I T I LINING r}I' l l '
<br /> PROTECTION.
<br /> 2; If OTHER,print in the space provided.
<br /> I . PIPING INFORMATION
<br /> 1. Circle'A"if above ground circle"U"if underground,and circle",` oth if applicable,
<br /> 2. If UNKNOWN circle;or if OTHER, print in space provided.'
<br /> . Indicate the LEAK DETECTION ECT"ION system(s)used to comply With the monitoring requirement for the piping.
<br /> V. TANK LEAK DETECTION
<br /> I., indicate,the LEAK DETECTION system(s)'usedo comply. e monitor ng requirements for the tank.
<br /> VL INFO
<br /> RMATION'ONTANK PERMANENTLY CLOSED 'IN PLACE
<br /> 1. ESTIMATED "T T tf T" ( an'ua ,1 r d 1 )
<br /> 2. ESTIMATED QUANTITY of ' STA remaining in the tank(inGallons).
<br /> WAS TANK FILLED WITHINERT MATERIAL? h "Yes or,140'.',,
<br /> 'TANK "T 1D REPRESENT T"I ` l) T",S t "DATE THE FORM AI
<br /> CATEP P (see s6ctiolri 2711 ( )(1 )CCR)
<br /> INSTRUCTION FORTHE LOCAL AGENCIES
<br /> The state Underground star ge tank identification number 3 con ed ofith two digit county number,"the three digit
<br /> jurisdiction number,the six di ff facility number and the six digit tank n bar. Thecourity,and jurisdiction numbers are
<br /> predetermined and can be obtained by callingis (. 16) 7 foci' number rn t e same as
<br /> Win formW, .atank number may b assn Ib . 6 'fir$t li number crust be nam 'an
<br /> 8..
<br /> cannot contain an alphabet. If the local agency prefers the Stag Board to,assign the tank number,please leave it blank.
<br /> >,
<br /> IT IS T° IF' 3F P N IBILITY OF THE LOCAL AGENCY 'THAT IN0P T TT t 'FACILITY TO VERIFyTHE U;-
<br /> , A F THE INFORMATION. THE LOCAL AGENCY Is RESP I LE F 'THE P I I F T"
<br /> OLOCAL AGENCY U L " INF R ATI BOX. THE LOCAL A F L . . Ali T H PI I AL
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