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INSTRUCT IONS FOR COIMd°L ETlfaf FOR ` ,.,#3
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of T",€ie 23, Division , Chapter 16, Cali,,"ornia Codcof Regulations and sections 25286, 25287, end 33239
<br /> of Chapter 6.7# Division 20, Health and 'Safety Code s"`<'quire tank owners to apply for an LIST operating permit,
<br /> ?, One FORt l "B" s#al: be,cora.pieted fai each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS L and/or any other TANK €NFOR ",A l 'CHANGE.
<br /> 2, This form should be completed ,y ei'f'ler the PERMIT PPLI £T_bi the LOCAL AGENCY UNDER-
<br /> GROUND-lANK !NSP1E_G-TOR
<br /> Please..# typer print i c rrp : li -q ueC. information,t
<br /> � 3" iP i inst 3
<br /> �, ��Gt 3'r�i£y �b„➢> t�ti'a��i�.S :"€.i E#", s ,you are making 3 copies,
<br /> „, Tank rn w.s � subrnit? clot plan-t he local agency showig filalocation of the USTs with respect
<br /> to buildings a-,-,d ititi,a df`r kS '271111
<br /> I (a)(8) C%I',' ],
<br /> Tank owners rr. ,s submit:�,�Urcentr tiara showing compliance with state financial responsibility require-
<br /> ments
<br /> equir°e-
<br /> rr Vii s lathe toy i'agency for ptroleurn USTs[27 i (a)(t t) CCR],
<br /> TOP OF FORM: MARK ONLY ON [. E.
<br /> Mark a 'X) in, the box next to ffie df r. that has"desi.".-ribes thoe reason the form i being ilm #feted,
<br /> lt;u. "°, ,. � a.c.li, ..,,” ";�yq r _,fie ;.e�nk,is installed,
<br /> 1. TANK DESCRIPTION - COMPLET E ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A, Indicate owners tank is 11,t.,re is a yank number r be of is used by the owner to identify the tank(ex.
<br /> 7379),
<br /> B Indicate the name oftrie cor npany that manufactured the tank{ex, ACME TANK MF(3),
<br /> Indicate the year the tank was installed (ex. 987),
<br /> Iw. Indicate the tank'"an a,3 in, oaHors {, y. 2,-,5,000 or 1,10,000 etc), _
<br /> IL TANK CONTENMS
<br /> A, 11. IF MOTOR VEHI ,,LE FUi,`:',1,_, ohe& box 1 and complete to items B& 1,
<br /> . It not MOTOR "f H1i-',LE FUEL,,ci h ck the at`,r€opriate box in section A and complete items B& D,
<br /> Check the appropriate bo .
<br /> l eck thio,type of MOTOR WOR VEHICLE FUEL(it box I is checked in A).
<br /> D, Print the chemical name of tinea hazardous substance stared in the tarok and the C. , .#, (Chemical
<br /> Abstract Sewice nur b r); if box 1 is, NOT checked in A.
<br /> IlL TANK CONSTRUCTION ;- MARK ONE ITEM ONLY IN BOX A, B, C-& D
<br /> t, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION
<br /> PROTECTION,
<br /> , If OTHER, print in the sr,,ace crovided,
<br /> C a#s'- A" if above g, and circle `U" if underground, and circle both if applicable,
<br /> 2, If UNKNOWN circle; or if OTHER, print in space provided.
<br /> 3, Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping,.
<br /> V
<br /> -1-ANK LAK DETECTION
<br /> 1, Indicate the LEAK bETECTIONsystem(s)used to comply with the monitoring requirements for the tank.
<br /> '°yl, INFORMATION O TANK f ENTLY CLOSED IF PLACE
<br /> s°
<br /> ESTIMATED ATA t"T USED -MONTH/YEAR (January, 1988 or0tl 3)
<br /> 2,' ESTIMATED QUANTITY ITY cf HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). ,
<br /> 3, WAS TANK FILLED WITH H IN eT MATERIAL? Check#`.° es" r"No",
<br /> TANK OWNER R AUTHORIZED REPRESEr T TIV MUST' SIGN AKD DATE THE FORM AS INDI- '
<br /> TED (see section 271 (a)(!3) CCR]
<br /> INSTRUCTION FOR 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 six digit facility number and the six digit tank number. The cciunty and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the States Board (316)227-4303, The facility number must tae the areae as
<br /> shown in form "A" The tank number 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 Mate Board to assign the tank number,ber, please leave it blank,
<br /> IT IS THE ESPON I ILIT OF THE LOCAL AGENCY THAT Ite r C<T s THE FACILITY TO VERIFY �l`H ACCU-
<br /> RACY O THE INFORMATION, THE LOCAL AGENCY IS 3 tNSI LE-FOR THE COMPLETION ION OF THE
<br /> "LOCAL AGENCY USE ONL INFORMATION BOX. T HE LOCAL,AGENCY,,„, l-tOULD RETAIN,THE ORIGINAL IIND
<br /> YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED Y THE TANl<. fNER.
<br />
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