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I TRU
<br /> -CTiONS FOR COMPLETING FOR " „
<br /> E INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code oft trc ita and sectio ns X5266,X5237,and 25288
<br /> Of Chapter 6.7, Division 20,Health and Safety Code require tank oL rt r t o ily for n UST operating pen-nit
<br /> t. One FORM"B"shall be completed for each tank fir all ,: FR ITS, PERMIT,CHANGES, ,:
<br /> ALS and/or any tither TAMC INFORMATION SHANGF,,.;
<br /> . This form should b completed either the PERMIT F L:I A T. r the.LOCAL,AGENCY Lf �R-
<br /> R } l TA ISS TtRa
<br /> . , ,
<br /> .- Fl ase type or print clearly all requested infprmati r
<br /> 4, Use a lard point writing instrument,'you are rhaking . pi X:
<br /> 5. Tank owners must submit a plat plat to the local agen -s in Iodation of the l Ts ith reaped
<br /> to buildings and landmarks(2711 (a)(6) R]m
<br /> . Tank owners must submit documentation showing c6mpliapmwl �respti �� ty,req€,lre� �
<br /> rnents t the local n forpetroleum STs 1 �� � .state ,
<br /> [ f (
<br /> TOP OF FORM: HARD ONLY ONE ITE
<br /> the box next le,the item,that best,0, n the reason s be,g a
<br /> . Indicat6,the A or Facility name*here the tank is installed,
<br /> I. TANK DESCRIPTION OOMPLETE ALL, ITEMS - IF UNKNOWN, 5 SP i
<br /> A. Indicate owners tank( «If ere i a n nu r that i y owner to ides,-" ��� X. .
<br /> AS707 9].
<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. 1967).+
<br /> D. Indicate the tank capacity in gall ns,(e s 25 r`10, etc.)..
<br /> U. TANk CONTENTS '
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and compte€eAorns .
<br /> 2. If T HIL L�,the a app plate. .in ' ` n A d complete kms D.
<br /> B., ; Check the appropriate box.
<br /> D. Check the type of MOTOR VEHICLEFUEL(if box 1,i oh dked in A)®
<br /> D. Print the chemical name of the hazardous substance star irr the tank And the ,A.S. ,(Chemical
<br /> Abstract Service number),-if box 1 is NCT'cheokein"A
<br /> Ill. TANK CONSTRUCTION -MARK ONE ITEM ONLY IN BOX ,'
<br /> 1. Check only one item lir TYPE OF SYSTEM,TANK A`t IAL I 1 LININGand,CORROSION
<br /> PROTECTION.
<br /> . If'OTHER,print in the space prod
<br /> Iii. PIPING INFORMATION
<br /> 1. circle„A"if above ground circle"U"If underground,and°circle both if appli Ie.
<br /> 2. If UNKNOWN circle;or if OTHER,print in space prodded.'
<br /> 3. Indicate the LEAK'DETECTION system(s)used to cornplywith th driltorin requirement,for th pipin'.
<br /> V. TANK LEAK DETECTION
<br /> 1. Indicate the'LEAK DETECTION system(s)used16 comply'with'the monitoring,rt irements for the tank.
<br /> L INFORMATION TANK PERMANENTLY, I
<br /> I. ESTIMATED D ATE LAST USED- MONTH/Y (Jariuiry 196 ;. r:C11iwy
<br /> . ESTIMATED OUA Tt ' f HAZARDOUS sus;3TANderemaini,10111inthe tank(inGallons).
<br /> 3. WAST NK FILLED WITH INERT MATERIAL? k* s*` " I ".
<br /> R AUTHORIZED. R � T`AT`IV ��t T �A AT� THS F AS I I-
<br /> AT [see section;2711 (a)(1 3)CCR]
<br /> INSTRUCTION, FOR THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is comps the� ` i b rs number,the throe digit
<br /> jurisdiction number,the'six digit facility number a the all di t tank num en Th county and jurisdiction numbdrs are
<br /> predetermined and n be obtain b filing the State 3'�rd-(91,45)2 7 p fa I num r rhi t�be t me-
<br /> ahem ih form"A". tank number may be assigned oto tb l ' erio �h e r;this biurfibiiir mUst'66'numedcal and
<br /> cannot contain n alphabet- If localagency pr ers e €a e r to a i n, um er,pleas l e i
<br /> IT IS THF RESPONSIBILITY,OF THE A AGENCY THAT RFT°S,.TFI '; ILI tO VERIFY THE At1-
<br /> RACY OF THE INFORMATION. T� LOCAL AGENCY IS R Sp NsisL FOA THE FL 1 , THE
<br /> "LOCAL AGENCY USE ONLY" INFORMATION5 ,,. THE . Al <A SOL R 1 ' fHE R€ IN, A
<br /> YELLOW COPIES. THE, PINK C* SHOULD RF .
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