|
INSTRUCTIONS FOR COMPL4WG FOR "B'
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, Iifornid Code of Regulations rid sections 25266x, 252x87,and �r
<br /> f Chapter 6.7,Division 20, Health mid Safety Code require tank owners to apply for an USToperating n °�It.
<br /> 1, One FORM "S" shalt be completed for each tank for all NEW 'ERMIT ,,,.. "SIT'CHANGES, R C)
<br /> ALS and/or any other TAMC INFORMATION H t E.
<br /> 2, This form should be completed by either the PERMIT APPLICANT or AGENCY UNDER-
<br /> GROUND
<br /> NDER-F UD TANK INSPECTOR,
<br /> . Please type or print clearly all requested informati nm
<br /> 4. Use a hard point writing instrument,you are Making 3 copies. i
<br /> . Tank owners roust subsalt a plat plan to the local agency showing the location of the with respect
<br /> to buildings and landmarks(2711 ( )(6)CCR).
<br /> 6. Tank owners rmest submit documentation shorting compliance v v.t,h state require-
<br /> scants to the Iocu, ,�� cy for petroleum LISTS(2711 (x)(11) R]
<br /> s„,O 01- FORM: Ar ,NLY ONE ITEC
<br /> 1. tar .n (X) in the box next to the item that bast describes the reason the form is being completed,
<br /> $t. Indicate the DBA or Facility name where the tank is fnstalr d.
<br /> it TANK DESCRIPTION COMPLETEAL's-L" 3 - IF UNKNOWN - SO SPECIFY
<br /> A, Indicate owners tank ID#m If there is n tank number that is used by the owner to identify the tank(ex,
<br /> AB 0 69)..
<br /> Indicate the name.-f the company that manufacturedthe tank(ex, ACME TANK MFG),
<br /> C. Indicate the year ttine, ank (ex, 1987).
<br /> e
<br /> D. Indicate the tz',.'.. c: t.,C,iri'3
<br /> II. TANK CONTENTS
<br /> A. 1. IF JOT r, I E I,'LL I��e , and comuiete items B&C.
<br /> 2. if not MC;TOR VEHICLEFU 'L, t ,,t . aqppopflate box in section A and complete items B&D,
<br /> F, Check trr ...=p box.
<br /> C, Check tise t d. ;# .. 'll? ' a.rt, . .}.„ ,�_ ,.,x a Is c1necked in A).
<br /> D. Print the chemical of ti'm. ..ubr ,i,c stored in the tank and the .A,S.#, (Chemical
<br /> 11, TANK CONSTRUCTION MARK I!M. 1"1", C`I.,w," ISI BOX A, RI C & D
<br /> . Check nn!y one,itenn in TYPE O& `,_ �. ., DI,,,°,.K MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> TION,
<br /> 2. If OTHER, n , in the space
<br /> 'IRI INF . I ed TION
<br /> 1. Circle"off" ifa,oov tgroun �c' cm ,� .�� a� . ��,.,rind,and circle bo h I applicable,..
<br /> , f UNKNO,A ,. .,.i," # y is 6?0 , print in p e provided,
<br /> 2.. Indicate the LE. .`( DETC s.0 SI sy t..., (s)used t)comply with the monitoring requirement for the piping.
<br /> TANK LEAK DETECI ,,'fl,,'
<br /> 1. Indicate the LEAK DETECTION system(s)need to comply with the monitoring requirements for the tank,
<br /> 'I, INFORMATION ATIC tl TgA!\1K PERI 'IANEN" 'L L0S1'rIII: IN PLACE
<br /> F m'
<br /> 1, ESTIMATED DATE LAST USED M t l FAIL (Januta , 1988 or 61/66)
<br /> 2, ESTIMATED QUANTITY of HAZARDOUS SUBST.AkNCE remaining in the tank in Gallons).
<br /> 2. WAS TANK 17111-LED WITH INERT MATS, II°a Check"Yes'or"No"„
<br /> TANK W R OR AUTHORIZED REPRE ENTA" I E MUST SIGN AND DATE THE FORM AS I I-
<br /> GATED (see section 2711 (a)(1 ) R
<br /> INSTRUCTION FOR THE FOCAL AGENCIES
<br /> The state underground storage tank identification number Is composed of the two digit county number,the three digit
<br /> Jurisdiction number,r,the six digit facility numberand thesix digit tsnk,n rob r. The county and jurisdiction numbers .ra,
<br /> predetermihed and can be obtained by callMd the State 875rN�rd(916)227-4303. The facility number roust be the sameas
<br /> shown in form"A". The tank€umb r 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,please Nave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY TGIF A U-
<br /> 'RA Y OF THE IS` F RPOATIO , THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION F THE
<br /> 'LOCAL AGENCY USE ," Nt,Y' INFORMATION BOX. THE LOCAL At E Y SHOULD RETAIN THE ORIGINAL IE'AL AND
<br /> YELLOW COPIES, TIME PINK COPY SHOULD BE RETAINED BY THE TANK OWNER,
<br />
|