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INSTRUCTIONS FOR COMPLETING FORM
<br /> GENERAL INSTRUCTIONS `'
<br /> Seor'r 2711 of Title 23, Division 3,Chapter 16,California Code of Reguiations'and sections 25286,28287,and 25289
<br /> de
<br /> of Chapter 6.7,Division 20,Health and Safety Corequiretank oy*Wm t6-' ` `r an UST operating permit
<br /> 1. One FORK!"B°shall be completed for each tank.f : ITS, PERMIT CHANGES, REM4V=,
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 2. This form should be completed by either the''PERMiT AIFICAI 'it the:LOCAL AGENCY UNDER-
<br /> s GROUND TANK INSPECTOR.
<br /> Fl 3, Please type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making3 opies
<br /> .. _ 5:- Tank owners-must submit a plot plan to the,local agencyshowin beat on of ffie USTs'with respe
<br /> 1 to buildings and landmarks(2711 (a)($)CCR).
<br /> 6, Tank owners must submit documentation showingcompliance with statdr it nc lxes .
<br /> p p `ssibityTequire-
<br /> ments to the local agency for petroleum USTs[2711 (a)(11)CCR].
<br /> T-OP-OF-FORM: MARK ONLY ONE 'ITEM _.�... _.
<br /> ` 1 AiMark-an�k(X).in the box-nextte the item that best describes the reason the form is beir$g
<br /> # 2. Indicate the DBA or Facility name where the tank is installed.
<br /> 4- I: TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPEC iF°{t'
<br /> A.- Indicate owners tank ID#-If there is a tank number that is used by the ownee'to Ideei- �, - K(Y.
<br /> AB70789).
<br /> B. "Indicate the name of the company that manufactured the tank(ex ACME TAMC MFG)Y
<br /> C. Indicate the year the tank was installed(ex. 2987)• „
<br /> _D. Indicate the tank capacity in gallons(ex.25,000 or'!+E),
<br /> II.,- TAkk-CONTENTS
<br /> A. 1 IF MOTOR VEHICLE FUEL,check box 1 and compl ..tems`13&C.
<br /> - y
<br /> 2.1-If-pot-MOTOR VEHICLE FUEL,check the appropri4 b6k frim A and complete items B&D,
<br /> B. Cheq_kAhe appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box i is checked A).
<br /> D. Print the chemical name of the hazardous substance stared in tank'and the C,A.S.#.(Chemical
<br /> Abstract Service number),if box lis NOT checked iri*`
<br /> Iii. TANK'CONSTRUCTION - MARK ONE ITEM ONLY IN''66k A,-:I3, `$ D
<br /> 1.- Check only one item in TYPE OF SYSTEM,TANK MATEI k, iNTERIOR LINING and CORROSION
<br /> PROTECTION.
<br /> 2. If OTHER,print in the space provided. w a.
<br /> k, IV. PIPING 4NF MATION -
<br /> - 1, Circle'Anif above ground circle°U"if underground, and circle both 0 applicable. ,.
<br /> 2. If UNKNOWN circle,or if OTHER,print in spare provided.
<br /> 3.` indica4the LEAK DETECTION system(s)used to comply with,the monitoring requient for tt)�aping.
<br /> V. TANK LEAK DETECTION
<br /> 1: > Indicate the LEAK DETECTION system(s)usedlo txxnply with the monitoring
<br /> requirements-for Owtarik.
<br /> _VI. INFORMATION_ON TANK PERMANENTLY CLOSED- IN PLANE -
<br /> i 1. - ESTIMATED DATE LAST USED-MONTHIYEAR(January, 1988°car 01/88) -
<br /> 2.- ESTIMATEDQUANTITY of HAZARDOUS Su TANCE remaining ire the tank(in Gallons).:
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL Ctreck"rtes"`or"No". ,
<br /> : .
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE Wg SIGN AND DATE THtF�.FGRM AS INDI-
<br /> CATED [see section 2711 fa)(13) CCR]
<br /> .. ,, _..,.• gyp. ,, :,-� :.. ,; --
<br /> INSTRUCTION_'
<br /> FOR' THt LOCAL AGENCIES ,' _ -- n
<br /> The state underground storage tank identification.number is comprised of the two digit county number,the three°digit
<br /> jurisdiction number,the six d'igit1acility num r arid"the gi digit tank number. The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(916)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" R
<br /> cannot contain an alphabet.Itf the local agency prefers the State Board to assign the tank number,pleaseleave it blank.
<br /> IT ISTHE RESPONSIBILITY OF T14E LOCAL AGENCY THAT INSPECTS THE 2�ACILITY TO VERIFY THE ACCU=
<br /> RACY OF THE INFOFIMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INFORMATION SOX"THE LOCAL AGENCY SHOUL' RETAIN"THE ORIGR A l�jliia
<br /> " YELLgWCOPIES. T J INK CQQY SHWI_63 :BE R NEiS AV-THE TANK, WNER,
<br />
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