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INSTRUCTIONS FOR COMPL,r19 FORM " "
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 'fin Chapter 16,California Code, f Regulations,andt=e a� 25286,25287, and 2528,
<br /> of Chapter 6,7, Division 20, Health and Safety Code require tank owners to appiy for an LIST operating p e
<br /> 1, One FORM "B" shall be completed for each tank for all NEW PERMITS, `","I' IT C<"ANGES, EMO'v
<br /> ALS and/or any other TANK INFORMATION G
<br /> p, This form should he completed by either the PERMIT PPLIC 1T or the u.>m� e .<w° .Elrf q7. F1.,
<br /> .; G T N TANK N E TOR,
<br /> Please type or print clearly all requested information,
<br /> Use a hard point writing instrument,you are making 3 copies,
<br /> Tank owners must submit a plot plan to the local agency showing the location of the ''JISTs with respect
<br /> ,ttq,buildings andl landr rks[2711 ( R],
<br /> 6. ankowpersm
<br /> z,st v bmlt documentation showing compliance%,ith state financial r ,,,,v sibIIit rdpraire-
<br /> menta to the;w, erg a cy for petroleum t • 1 1 CCR].
<br /> -T0 OF FORM: MARK ONLY ONE ITEM
<br /> 16 Mark an t f,_in the box next to the items that beet describes the reason the form is being completed.
<br /> , Indicate the DBA or Facility name where the tank is installed,
<br /> I: TANK DESCRIPTION - COMPLETE ALL. � � � IF UNKNOWN - SO SPECIFY
<br /> Via, Indicate rnorlera tank I -If there is a tank number that is used by the owner to identify the tank(ex,
<br /> Io7? t,
<br /> , Indicate the name of the company that manufactured used the tank (ea,ACME TANKMFG),
<br /> C, Indicate the year the tank was installed (ex, 1987),
<br /> D, Indicate Sty to u.r,, in{,'€Iona x,25,000 or 0,wa0 ? ,A..
<br /> IL TAMC CONTENTS
<br /> A. 1, IF MOTOR VEHICLE CEL, check boa 1 and complete items B&C.
<br /> . if not MOTOR VEHICLE FUEL, check at,e appropriate box in section A and complete items B&Dd
<br /> B. Check the appropriate ou..
<br /> C. Check the type of NIRDT R VEHICLE ,c:fLIEL of box 1 is checked in }m
<br /> Print the chemical name of the hazaudouqs substran e stored in the tank and the a w . , (Chemical
<br /> Abstract Service number),ber), d"_ox 'i °,. . Ey .hecked it A.
<br /> III, TANK NSTRU w,Tlr,N- MARK ONE - F ,.N'L. IN BOX A; B, C & D
<br /> 1, Check only one fterg,, 4,,TYPE f °. . '°'_ _ '>� MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> g° If OTHER,p n"in the mace prr_vId .!.
<br /> I x PIPING INFORiVIATION
<br /> 1, Circle"A"if above ground ci cie Ufunden ;e< rsf,and circle o i applicable.
<br /> 2, If UNKN VJ'N circle or it Cif"HE IR, print in space provided, ,
<br /> Indicate the LLN<DETECTION system(s) used to comply with the monitoring require-mest for the piping.
<br /> V, TANK LEAK ET=A T."'°`rf
<br /> 1° Indicate the LEAK DETECTION sy teas(s)w sed to comply with the monitoring requirements for the tank,
<br /> , INFORMATIONS ON TANK MANEN IILY CLOSED IN PLACE:
<br /> 1. ESTIMATED DATE LASTUSED-MO T NE R (January, 1988 or 01/88)
<br /> C° ESTIMATED QUANTITY of HAZARD t,.,., SUBSTANCE NC E reemainin in the tank in Gallons).
<br /> 3WAS TANK FILLED,WITH INERT MATERIAL? Check"Yes'or"leo
<br /> TANK OWNEROR AUTHORIZEDE fESENT TIE MUST SIGN DATE THE RINDI-
<br /> CATED (see section 2711 (a)(1 Gl
<br /> INSTRUCTION FO THE LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county number,the three digit
<br /> jurisdiction number,the sly digit facility lnor nber Arad the shr digit tank number, The county and jurisdiction numbers are
<br /> predeteIrmined and can he obtained by calling the State Board 1,916) a The facility number rout be the same as
<br /> shown in form 'A". The tank number may be assigned by the local agency,however,this number must bre numerical and
<br /> cannot contain an alphabet, it the local agency prefers the State Board to assign the tank number, please leae It blank.. .
<br /> IT IS THE PO I IL IT OF 'TIE LOC LGEN'C THAT It FET THE FACILITY T 'f VERI THEACCU-
<br /> RACY CLF Tl I FORkA ATk) , .THE LOCAL E . T"IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ,1LYA ' INFORMATION OX. THE LOCAL L AGENCY SHOULD RETAINTHE ORIGINAL t
<br /> YELLO\q'-COPIES, 'THE PINK COPY, SHOULD E RETAILED BY THE TANK OWNER.,
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