BILLING - Laserfiche WebLink

Home Browse Search

IN51'RU(NIONS FOR COMPLInING FORM"13" GENERAL INS-MUCIIONS: 1. One FORM "B"shall be completed for each tank for all NEW PERMI71N,PERMrF CIIANGF.S, REMOVAIJS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPIJCANTor the LO(W.,AGEN(-Y UNDERGROUND TANK INSPEC170R. 3. Please type br print clearly all requested information, 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM: "MARK ONLY ONE rM.M* 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK DESCRIPTION-'COMPLFTE Au.rrums-IF UNKNOWN-So SPFX,1FY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank(ex. AB70789), B. Indicate the name of the company that manufactured the tank (ex. ACMETANK MFG.). C. Indicate the year the tank was installed (ex. 1987), D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). If. TANK CONII.?NVS A. 1. If MOTOR VEHICLE FURL,check box and complete items 13& C. 2. If not MOTOR VEIIICLII FUEL,check the appropriate box in section A and complete items B &D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1.is NOT checked in A. Ill. TANK CONST'RUCT'ION-MARK ONE n73m ONLY IN W.)X A, 1.3,C&D I. Check only one item in TYPE' OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTTIER,print in the space provided. IV. PIPING INFORMS110N 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DETEcriON system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DHI`EC'I1ON 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMA7110N ON TANK PTIRMANEN11,Y CLOSED IN PIACI? 1. ESTIMATED DATE LAST USED- moxf-ii/yEAR(January, 1988 or 01/88). 2. EsnMATF,11) QUAN'ITFY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT N1XrF'1R.1AL? Check 'Yes' or'NO'. APPI1CANI'MUST SIGN AND DA11?'I1IE FORM AS INDHWIFI). INSFRUC71TON FOR 11IL LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction number,,,, are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. rI'IS`H1E?RMPONSIBI[Il"Y OF 111E LOCAL AGI.?NCY'IIINN'INSPFL.(71N'IIU'?I?A(.'ILrt'Y TO VERIFY 11111 ACCURACY OF`I7IE INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBIE FOR"IF COMPLITIION 01711IE *LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM 4A"AND ASSOCIA71'ED 1`1)RM-Ir(s)-IU 111E IULLOWING,ADDRESS. 9rA1` OF CALIFORNIA SE'A'T li W/VITR RFNOURCTLS CONI'R,01,BOARD ON11A PKO,,J?&iiNO CTI',NlLi% E0. BOX 527 PARAMOUNT,CA 90723