|
F
<br /> INSTRUCTIONS FOR COMPLETING FSR
<br /> GENERAL II TRU TI I
<br /> eptl rl 2711 of Title 23, Division 3,Chapter 13,California Code of Rens ria ions and secticsns25286,25287,and 25289
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank o ner .dap sly for an LIST operating permit,,;
<br /> 1. Ono FORM"B"shall be complete 1of each took for dtl t W PtRMI'° ,PE R (T AE P
<br /> ALS,ardlor any other TAF IFFIMAT l CHANGE.
<br /> 2. 'This form should be co plet d by either the P15RMIT A ANT the LQCALAGINCY,,VJNP,128�
<br /> GROUND TANK INSPECTOR.
<br /> 3. , Please;t pe or print clearly all requested into ation.
<br /> 4. use a hard point writing instrument,yoars raking,3..00pie&
<br /> . Tank owners roust submit a plot plan to the local agency shoving th location ofAhe U TS with
<br /> to buildings and landmarks(2711 (a)( ) R).
<br /> 5. Tank owners roust submit documentation showing compll nce It : tafi financial respon ibiiity req ira "
<br /> ments to the local agency for petroleum USTs[271 i(a)(1 )CC,Rf
<br /> QP OF FF : IRK ONLY ONE ITEM
<br /> 1 Markan(l )in-the box next td the item that best describes e r on. ego i °= (rrg,cP l ed.
<br /> Indicate the DB or 'acidity Mame where the lank i .installed.
<br /> I.
<br /> TANK DESCRIPTION - COMPLETE ALL ITEMS IF 'UNKNOWN,r:,SO SPE IFY
<br /> A. Indicate owners tank ID#-If there is a tank'numbeir thatisustd,bythe,owner to identify, k( .
<br /> 70789).
<br /> S. Indicate the name of the company that manufactured the tank(ex. T F ).!
<br /> C. Indicate the year the tank was installed(e .;13 ),
<br /> D. Indicate the tank capacity in gallons(ex.25j000 dr, , o etc.).
<br /> 11. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and complete items; C.
<br /> 2. If not MOTOR VEHICLE FUEL,check the a pro rratbdx,lin sect A,and complete items
<br /> B. Check the appropriate box.
<br /> C. Check the'type of TR FILL FUEL(if box is ch in ).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and ft . . .#, ( hemicat
<br /> Abstract Service number),if box Vie NOT checked in A;
<br /> Ill. TANK' CONSTRUCTIONA IT L I , ,
<br /> 1. Check only one item inTYPE FSYSTEM,TANK MATERIAL, INTERIOR Ii and QQRR0810.N
<br /> PROTECTION.
<br /> 2. If OTHER,Print in the space provided.
<br /> Its, PIPING INFORMATION �
<br /> 1. Circle" "if above ground circle`U"if undergrounds and ckrblab6th ifspiplipable. d
<br /> 2. If UNKNOWN circle„or if OTHER,print in space r vid d.
<br /> 3. Indicate the LEAK DETECTION system(s)used to dorholy With the monitoring requirement foirth n ti
<br /> V. TANKLEAK DETECTION
<br /> 1. Indicate the LEAK DETECTION system(s)used to open ly with the- onitornirern fir
<br /> ' I. INFORMATION TANK PERMANENTLY CLOSED IN PLACE '
<br /> NT (Janusy '6or0 )81ESTIMATED AT T USED
<br /> . ESTIMATED QUANTITY of H R LIS UB TA F remathin in e tank(n Gallons).
<br /> . TANK FILLED WITH INERT ATFRIAL Check des!or o"
<br /> TANK OWNER,OR, AUTHORIZED RFP T TIV T. ( A ; DAT" Tf F I D k,.
<br /> GATED [see section 2711 (a)(1 3) CR]
<br /> INSTRUCTION, FOR, THIE ,LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county rlsarnber, e the di it
<br /> jurisdiction number,the six digit facility number acrd the six digit tank number. county and jurisdiction numbers4tre
<br /> predetermined and can be obtained by calling the State and(916)` .�, d facie n m r t
<br /> shown in form"A". The tank norm r may e signed by the loll h j,.hcr rj this number must hU M t rl
<br /> cannotcontain an alphabet. If the local agency,Prefers the Mate rd to assign#*tank rum ,please,leave it blank.'
<br /> IT IS TGIF RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS= THE FA ILI TO VERIFYTH A i�
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS REtPONS143LE FOR THE COMPLETION OFTHE
<br /> "LOCAL AGENCY USE ONLY, INFORMATION BOX: THE LOCAL, N Y R 'P All THE, ORIGINAL AND
<br /> YELLOW COPIES. THE BINKCO U AINE1 TA
<br />
|