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<br /> `INSTRUCTIONS FOR COMPLETING FORM
<br /> > IRAL
<br /> INSTRUCTIONS s€; -
<br /> 2711 of Title 23, Division 3,Chapter 13,California Code of Regulations and sections 25286,25287,and 25289
<br /> Of Chapter 6.7,Division 20,Health and Safety Code require tank owners to apply for an UST operating permit.
<br /> 1- t)ne FOAM"B"shall be completed,for each tank for all NEW PERMITS,PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFOFIMAT16N CHANGE.
<br /> 2. This farm should be completed try either the/PERMIT APPLICANT or the,I,,OCAL AGENCY UNDER-
<br /> ' GROUNUTANK INSPECTOR.
<br /> 4. Use a hard point writing instrument,
<br /> - 3. Please type or int clears all requested information-.-
<br /> 4.
<br /> nformation: : .
<br /> p • g You are making3 copies. 4
<br /> 5. Tank owners must submit a plot plan tache local agency showing the location of the USTs with rem.
<br /> to buildings and landmarks t2711 (a)(8)CCR]. _
<br /> 6. Tank owners must submit documentation showing compl#ardbe with state financialresponsibility regtftre-
<br /> meats to the focal-agency for petroleum USTs[2711(a)(17)CC:R]
<br /> _.,TQP_-OF FORM: MARK ONLY ONE ITEM
<br /> 1. �Mark an (K)in the box nextto.the:iter,rr best describes the reason the farm is being
<br /> - 2 ,Indicate the DBA or Facilitylname where the tank is installed.
<br /> 1. TANK DESCRIPTION.- COMPLETE ALL-ITEMS - IF UNKNOWN SO _$1RECIFY
<br /> A. •Indicate owners tank ID#-If there is a"'number that is used by i f, owner to ider,;��{ �a k(ex. $
<br /> AB70789). _.
<br /> B. Indicate the name of the company that manufactured.the,tank(ex.ACME TANK MFG).
<br /> C. Indicate the year the tank was installed(ex. 1980.
<br /> D: indicate the tank capacity in gallons(ex.25,000 or I0,000"etc.).
<br /> il. 'uNk"CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items B&C.
<br /> ' 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D.
<br /> B. Check the appropriate box. ", r
<br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.NS.#.(Chemical:
<br /> Abstract Service number),if box 1 'is NOT checked:in A. y" `
<br /> III. TANKCONSTRUCTION - MARK ONE ITEM ONLY IN`16d A,'--B, 10'&'.'D
<br /> 1. Check only one item in TYPE"OF SYS` f—M,TANK MAT9141 INTERIORLINING and CORROSiC if
<br /> PROTECTION.
<br /> 2; If OTHER, print in the spar provided. ,
<br /> PIPING INFORMATION
<br /> 1. Circle A"if above ground circle-U"if underground,and circle both If ap;i ; ble.
<br /> 2. If UNKNOWN circle;or if OTHER,print in
<br /> ` space pt'avrded. ... ., ;• eAy
<br /> 3. Indicat '�hhe LEAK DETECTION system(s)Rused to.gomply with. ie monitor g requirerpent for the�kiptrtg,
<br /> V. TANK LEAK'[DETECTION
<br /> 1. Indicate the LEAK DETECTION systeirn(s) d t6i comply witfr the monimft.requirements forthe tank: -=
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED 14 PAACE:
<br /> 1. ESTIMATED'DATE LAST USED-MONTHIYEAR(January, 1988 or 01/88), _..
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallon's). a
<br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check"Yes"or"No".
<br /> .TANK OWNER OR AUTHORIZED REPRESENTAT[Vt,MUST SIGN AND DATE THE FORM-AS INDI
<br /> CA`fED [see section 2T1j'(a)(13)CCR] -
<br /> INSTRUCTION FOR THE LOCAL- AGENCIES 4 "
<br /> The state underground storage tank identification number is composed of the two digit county number,the throe digit,
<br /> jurisdiction number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers dtire
<br /> predetermined and can bbtained by calling the State Board(916)227-4303, The facility y niimber must lle thaeerrreFasL-
<br />` shownin 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,pleaseleave it blank
<br /> d _
<br /> iT IS THE-IESPONS-0LITT OF THE LOCAL AGENCY TI#AT;-I.MSPECTS THE-i FMLiTY-TO VERIFY THE_ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSI E FOR THE COMPLETION OF. THE
<br /> I LOCAL AGENCY USE ONLY- INFORMATION BOX. THE LOC
<br /> Y SH ETAIN THE;ZJAlGINAL AND m
<br /> YELLOW COPIES. THE,INK CC SHOULD BE RETAI�IELT �T ANt(,A �.;-
<br />
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