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INSTRU'C"I"ONS 'FOR
<br /> GENERAL INSTRUC1,110tJS
<br /> o' Reuulat'ons and sections215286, 25287, and 25289
<br /> Section 2 71i� of Tifle 23, Divisiorn Ca�or�
<br /> of Chapf,,,,,r 6,7, Di ..i#....'i 20, ,,,,ui,e tamk ok�tners to applyforan UST operating permit,
<br /> OORM 'B" Shail, be ,-�:ompleted'H_. oa& 1,anik far all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ne tF
<br /> ALS and/or ax'!L other TANK INFOR!',,--,,\'i i0itil CHANGE.
<br /> 2, This form shotfldl b�complet, d 'hv eior *6hv.,.x PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> 1"iROLIND TANK PNSPJE(`-'
<br /> A
<br /> P�
<br /> 3, 174=,a,seor -it
<br /> 4, Usz,,a 'nard €
<br /> r
<br /> o,
<br /> ple
<br /> P!an �o titlr7 agcllncy sshowing the location ofthe USTs with respect
<br /> `7" 1' tFll
<br /> r, J s�,,ow�ing co�np!ianice with st,�,te'i,,iari6,�' respons�Ibility require-
<br /> i ank oo must sibrnU J
<br /> mc,mts to flhe!r', .1,# agen,,-,y for petrole-mi USTs [2711,1 `a)(l 1) CCRI
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> box no,xtt t0t sc�bes the reason the form is being completed,
<br /> Mark an (X) in the the that best de
<br /> i
<br /> 2. Indicale the DBA a,,-Facility namp wh�,-:re the fanK ,,stalled,
<br /> I
<br /> L TANK DESCRIPTION - COMPLETE ALL ITEMS ® IF UNKNOWN - SO SPECIFY
<br /> 'A. Indicate owners tank ID Ifthere is a tank number that is used by the owner to identify the tank(ex.
<br /> AB70789),
<br /> B, Indicate the name of the company that met)ufa(.,,!u red the tank (ex.ACME TANK MFG),
<br /> C. Indicate the year the tanktvas ln3taIIt-,-,d i"ex, 1,9871,
<br /> D. Indicate the tank cap,,,,,i,,dty'ffi aalions ,Px, 25,000 ov"I 01,0000 et%`i
<br /> 1, TANK CiDN'TENTO
<br /> S
<br /> A> 1, lF tv13 l'0R \1Ei,'I!,,C',LE F1-11 ,_ n-t,,ck tox 11 aindtcompiete- ftenns B is C,
<br /> 2, if not NIOTOR ,a€_1 `p "UEL,orwok It,a apprc)pnhate box in section A and can plele items B& D,
<br /> B, Check the appro priat,-3 box,
<br /> 17 checked in A),
<br /> G, Check the pipe of NIOTOR VEHICLE- _� I I
<br /> I Ut- il
<br /> L !r,= I rs
<br /> D, Print the chennical name of the hazardous si.,,bstante stored in,the tank and the C,A,S,4,. (Chemical
<br /> 11,9"Ked in A,
<br /> Abstract Service number), if 111",ox 1 is N YT Ct I A
<br /> Ili. TANK CONSTRLJCT'ION '-'MARK ONE F'EM ONLY IN BOX A, 6, C & D
<br /> I- Check only one kern In TYPE OF SYSTEass TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> 2, O-rl 1`"-R, orit in the space provided,
<br /> Ifo
<br /> IV, FIRING INFORMATION
<br /> 1„ Circle'A" if above,gmund NUde
<br /> I' 'f unrground, and circla-both if applicable,,,
<br /> n Cen ;
<br /> 2, If LJNKN`3yVN circ-le; 0"rHIESR'�, ,,mmt in -,,a p-0video.
<br /> 3, l -ate the i__1EA',K'
<br /> 111�'11�1'iON uS`t(J 1-)Irnply wirb'the nionitoong requirennenti"X the piping,
<br /> VTANK LEAK DEI
<br /> Indlca,te the UEAKI`)ETEGPON sy,_-,1',_,,,,e a imed to cct7iply with the rrionitorina reqUiren-rents far the tank,
<br /> VL !NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> ESTIMATED IDArEE Lark")f N1-C,,,NTR-bYEAR -1january, 1988 or 011188)
<br /> 2, E'S TitJlATED OiJANITiTY of'HAZA' 'PiE OUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 0 WAS I'ANK,FILI ED WiT!-1 !N,`,`1'- ATERIA1,_? Check �'Yes`or"No",
<br /> TANK Oy`i1NER OR ALJTHOR��,Z`ED Ml IS7 SIGN AND DATE THE FORM AS lNDI-
<br /> CAI-ED [seesectw, 2711 (aI(-V73`l ',-"CR],,,
<br /> 1NISTi7ILK"TION FOR 'THE LO-03AL AGENCIES
<br /> The state undergrm-mri storage tanic id ,nl .�,,",,,�, O'ol�, riumbetis compoved of the two digit county number,the three digit
<br /> iulri5scliction nurnber,lkhe fa,il;ty nunnbeL,and the -,d i+ is on humbers"are
<br /> jqpcib�, This county w
<br /> -4303� The facility nUmber must be the same as
<br /> tme,djetermined and can be obtain,,,,d by caig'he State Board,t`16';�27
<br /> shown in i-ormi 'W, The May be assigne,,J by the local agency, however,tHs'number must be numerical and
<br /> 11thm-,Local agericy prefeisihe,State Board to assign til a tank number, please ie a'1'it blank,
<br /> I-L E 'NSIBUTY OF THE L(X_�Al_ A(3ENCY THAT INSPECTS THE IFACILITY 'TO VERIFY THE AICCU-
<br /> I,Ei TH E RESP(-)
<br /> RACY,OF THE INFOIRr ATiON, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION 0,F THE
<br /> AGENCY LISEE ONLY" INl-':ORN1A',f1ON DOX, 1-HE LOCIAL.LAGENCY SHOULD RETAIN T HE ORIGINAL AND
<br /> YELLOW COPIES, "HE PINK SHOULD BE ,RETAINED BY THE T'AF' JNFR
<br />
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