|
INSTRUCTIONS CR COMPLETING 'FORM .B" J
<br /> awn N",,, 3 i+.F ,i N_.
<br /> Section 27 f . of €i,'e 2"1", c..i vision ..s ;..�� a,�l„�y:f`:'.r s i,; '�.,ra�`.. ..�€r.i:a�.0 dle of ei=jul a`'o ns �E d �:ast,";�:.��.�'� �50.., ,�,c'? 'a; and��
<br /> of Chia,i,.,r. {�, D .,..._; 20, iezil E n?r .Safety! ,ety . ..�_ , ( ., a-U k uxv,n s s to apply for an UST operating permit.
<br /> , s l �E PERMITS,ITCY � T MI 'CHANGES, REI -
<br /> OnFO ,M ` n, } iF co �, � d f. . each t.�_ %r
<br /> ALS and/oran,,v other TANK lMP"ORI`V,ATlON CHANGE,
<br /> 2. form should 3, _,u 'p i.,'I:e`a by el., e ,,ie �Yr..FtMI I�APPLICAo are LOG �7�AGENCY UNDER-
<br /> This :
<br /> .3. ''ease type or print clearly all requet.,qd Fn orm tion.
<br /> 4� Use s herd point writing Instrument, you are making 3 copies.
<br /> Tank owners must submit o plot plan to the local agency showing the location of the LISTs with respect
<br /> to build=n s and l ndm rks (2711 (e)( CCR],
<br /> Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum LISTS[2711 (a)(11) CCRI,
<br /> TOP �F ,FORMI iii K ()NLY ONE E-M _
<br /> . `. t tt. box w to "he iterthat best describes the reason the form is being completed,Mark ai -
<br /> �= Indico, -'`B _ srF�a,�a,.e ra�,�,l �1I" E.. fl?: �.� installed._
<br /> L TANK DESCRIPTIO COMPLETE ;',_I,, ITEMS IF UNKNOW' SO SPECIFY
<br /> A, Indicate owners tank ID if fl e, a',tank k riu _b. .€at is used by the owner to Identify the tank(ex.
<br /> B7 07 3 x°
<br /> l 3.€?: tl e namef the C7r pry >. rnant.ifactured'he tank(ex. ACME TANK 1 M ,
<br /> Indicate the year the tank was installed (ex, 1987),
<br /> .D, Ir a cafe t ha tai; k ..<'ak.becisy in g.k_ail,.na kl ,,. .......2,00,.,?(ar 10,0.10 ea
<br /> FI TANK CONTENTS
<br /> A. 1, IF MOTOR i»OR ry I"11..''F FUEL, check box 1 and complete it m B& C -
<br /> 2, If riot MOTOR VE3 ICL FUEL,,check the appropriate box in section A;and complete items B&D.
<br /> ,. Check the approorI _`; box.
<br /> C„ Cr,,.r,_k the type of MOTOR VEHICLE FUEL(if box 1 is shocked in ).
<br /> D, Print the chemical name of (.r`e n€.a.z at"jous.,s ud',,.tante stored ;n the tank and the . .S< . (Chemical,
<br /> Abstract Service nu'l "`,C er), #`box, 1 is NO, i checked in A§
<br /> lit. T NK ()INS"�„Rl�t;�a''"`IO J - MAR ONE ITEM ONLY IN BOX , , & �
<br /> 1, Check only one'stern in TY PES OF SYSTEM,TANK MATERIAL, INT ERI R LINING and CORROSION
<br /> 2, If OTHER. orint in the space provided.
<br /> ,
<br /> 1, Circle le€rAif above ground d ,.i;r is "U" if underground, and circle both if applicable.
<br /> bgle.
<br /> If UNKNOWN oar=.lea or If OTHER,rprint in space provided,
<br /> 3Indicate the LEAK DETECTION TION systern(s) used to comply with the monitoring requirement for the;pipin .
<br /> V. TANK LEAK DETECTION
<br /> I. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements fir the tank.
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> F' ESTIMATED DATE AST USE f7 a2ET HNEAR (January, 1988 or 01,188)
<br /> ' ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br /> 71 WAS TANK FILLED WITH I R-1- IIAT E I L y Check "Yes"or"No",
<br /> TANK OWNER NER R AUTHORIZEENTATIVEM SF J 0'.' THE CS M AS INDI-
<br /> CATED (see section 2711 (a)(13) 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 dint tank number, The wunty and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board 191 6)777-7303. The facility number must be the sante as
<br /> shown in f grit " he tank number rpay bre assigned by the local agency,however,this number must be.numerical and
<br /> c isnot.,sc ntsii� an alp=habet, If the local agency prefers the;Mate Board to assign the tank number, please leave it blank.
<br /> IT IS THE i RESPONSIBILITY OF THE LOCAL AGENCY° ' 'HAT INSPECTS THE ILI Y TO VERIFY THE ACCU-
<br /> RACY OF THEINFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OFTB
<br /> }LO'1'.,'AL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY_.SHOULD `t`AIN TI'TS ORIGINAL N
<br /> YELLOW COPIES, :T H I .3 i� . .;"Y SHO c E RETAINED t T Y THE AN i R
<br />
|