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INSTRUCTIONS FOR COh,1P
<br /> GEN EERAL INSTRUCJlOt_11.S
<br /> Seli-ton 2711 of Title 23, 4..
<br /> 1-ps 25286,25287,and 25289
<br /> of Chapter 67, Division 20, Heait ,,, �,�perating permit.
<br /> RE
<br /> 1. O'ne FORM, ,sten foi, - r all Nf MOV-
<br /> 'i"J'FORM?1,
<br /> 2. T
<br /> h�s lonn t J a by x. "L AGENCY N ER-
<br /> S< Please tvT �eauest, ""'n,
<br /> 4. Use a Dara; oow,-
<br /> 5 -Fanik t i ot P I a n i Agency shov,;-riq j ra�iGn of tne US7 s with respect
<br /> I c c 0 M P 1 i an,,-,ev, :stale 1'n,�anpial responsibility require-
<br /> 6� T
<br /> _2711 (a)(1 1) C""Rij
<br /> U3 �ol petroieum, US
<br /> -M
<br /> OF FOR' 'A rF�
<br /> 1, kla_�a :1', nex,tr,,,,,, the ft;,rn desv,ibes the reason the form is being completed,
<br /> 2 1 n d i t 10i",
<br /> R,
<br /> installed,
<br /> TANK DESCRIPTiC, � .,'CMPLETE ALL. ITEMS IF: UNKNOWN SC,
<br /> A. Indicate vnk riLmber that is used by the tank(ex.
<br /> AB7f'IV78�',
<br /> I
<br /> S. the f the com, r,-�d fne (ex. AC` 1E TANK MFG),
<br /> C, Indicate 111h,-o, < tank eta.
<br /> QU
<br /> 1). Indicate the
<br /> 00
<br /> TANK CONTENTS,
<br /> A.
<br /> -onn,- -arns B C.1, IF MOTO�Fi and pleTe ill,
<br /> E b,,x vi section A iterns B&D,
<br /> B. F:he,*th
<br /> C,
<br /> te Oneck the tv � -,�j�,_,rZ
<br /> 1 s ecked n A).
<br /> D. Pnntthe chernic,_,,,�
<br /> 5'_� Q Q L an;tank athe C.A.S.#. {Chemical
<br /> AoSlvact Sth tenACc i,,�,dn A,
<br /> A� BC & D
<br /> TANK 'C�ONS TRU', IN BOX g
<br /> ZxA�NK MATERiAL, IN—ERI }R LININkC3 and CORROSION
<br /> ", C�
<br /> 2,-. if OTHI,'�,
<br /> V
<br /> IRISIN G 4IF"OR!"
<br /> 1 Circ.e "A"'i aho,',s, j,nd,and circ-ld both If applicable.
<br /> 2, If UNKNOW',N o� i"',
<br /> �nf 0 Provided,
<br /> I In"J
<br /> !:J�r requremelt for the piping.
<br /> V, TANK LEAK
<br /> 1, indicate the LEAK DETECTION system(s) us r,to coanply with the rnonitoring requirements for the tank.
<br /> INFORMATION ON TANKPEFRIMANIEENTLY CLOSEIN PLACE
<br /> 1. ESTIMATED IDATEE LAST' LIS111"D (January, 1988 or 01/88)
<br /> 2. ESTIMATED, 6J'1'4D", :JJW7ANCF_ remaining in the tank (in Gallons),
<br /> 1 WAS TANK Fi�_,,,J".-"LJ VoO,' ,� d"',
<br /> or
<br /> TANK (,,,WNER OR ALITHORIZ"'E"D REF-��LSI_,? '-'--'V" MUST SIGN AND DATE THE FORM AS INDI-
<br /> 's section 2711 (a)(13) CGRJ
<br /> FOR THE LOCAL AGEPJGHE'_'tt
<br /> to underg A sioragt--� ,unk cwr,Posed of the two digl�lt,,,,,oun�,j number,the three digit
<br /> six 6i,,;t ;,,anr iliit '- -id Jurisdiction n mbers are
<br /> Aion numb� nurnbi�, tanknumber, rho c`ounty w u
<br /> e'a
<br /> M 227 ()& Th
<br /> SMV-,riiaw 911, 1 -43 . hz,faciY y riUmber'musrbe the same as
<br /> 1,,vthre local-agpncy,�owever, this number must be numerical and
<br /> contai, pr i3c,,,ird tiassign tine tank number, pease leave it blank.
<br /> 31UTY TO VERIFY THE ACCU-
<br /> 'rHE RESF ., B!L
<br /> RACY OF THE INF ORk,,,, Tir SESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> THE TANK 014,1NE19,
<br /> YELLOW COPIES. THEE P, �Ni K,
<br />
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