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4 <br /> INS I.°RU(N IONS FFR-,1"'0MT`1_V1'NG iZO "1V <br /> f EWERAI, `�1'RUC;FIONS: <br /> L One FORM "13"shall be completed for each tank,for all NEW PGRMTIS,PI3RMI'1'CHANGE?S, RIIMOVAI.i and/or any <br /> Other TANK INFORMATION CHANGE. <br /> 2. 'I:his form should be completed by either the PE 'APPLICANT or the LOCAL AGENCY IJNDFRGROUND'TANK <br /> INSPI—FOR_ <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hand paint writing instrurhen't;you are irtaking,3 copies. <br /> TOP OF FO RK ONLY ONE ,M" <br /> 1. Mark an (X)int the lioK'next to the item that best describes the reason the form is being c")mplcted. <br /> 2. Indicate the DBA or Facility name where the tank is installed, <br /> L TANK DE,SCRIVI1ON-COMPLEIM ALL ITEMS-W UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex. A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex.. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). ; <br /> II. TANK CON" a • <br /> A. 1. If MOTOR VEIIICI.,E FUEL,check box 1 and complete items B& C. <br /> 2.If not MOTOR VEHICLE?FULL,check the appropriate box in section A and complete items 13 cot D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical Abstract Service <br /> number), if box I is NOT checked in A. <br /> III. TANK C ONS RUC`EION-MARK ONE rI'IW ONLY IN BOX A,E3,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTI.iC HON. <br /> 2. If O"ITIER,print in the space provided. <br /> IV. PIPING INFER TION <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN.circle; or if O'IHFR,print in space provided. <br /> 3. Indicate the LEAK DE1'E'C"I'ION systems)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DHI1W—t1ON <br /> 1. Indicate the LEAK DEFEC11ON system(s) used to,c<omply with the monitoring requirements for the tank. <br /> VI. TNFORMA7I1ON ON TANK PI!RMANFM1..Y CLOSED IN PLACE <br /> 1,. E'sSI'1MATED I)A'TE LAST USED-MC)NTII/YE^'AR(January, 1988 or 41./88). <br /> 2. E911Mty.':[FI3 QUAN''ITI-Kof 1€AZARDOUS UBSTr1NCF,remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLET) WITH INF'RT MA'IT ,\L? Check 'Yes'or'NC)'. <br /> APPLICANT MIDST SIGN AND I)XII-711-YE,FORM AS IND10VIT21 <br /> INISTREJCT1ON FOR'F1JE LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction' ' <br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling;the State Board (916)739-2421. The facility number must be the same as shown in form "A". The <br /> tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If <br /> the 4ocal agency prefers the State board to assign the tank number,please leave it blank. <br /> IT IS TILE RI SI'O�SIT311.f l Y C,)I "T TIE?LC)(AI. C`sE NC'Y`I IIAT INSPEIIS TIII?FA('ILTIY'I O VI3RII"Y TIII? <br /> ACC'URA(,'Y OF°Illl?INlst:)ILMNI'TON. 11II'f 1 f)C'AL AGEiNC:Y IS R:SPONSH31E1 FOR 11113 COMPLETION OF TIIE <br /> "LOCAL AGIT.N( Y USE ONLY' 1NI )RMA`l1ON 13OX AND FOR FORWARDING ONE FORM"A"AND A.SSOCINIED <br /> EX)RM "B"(s)'I 'D IIT F 1LL(- WING ADDRE-RS, <br /> S OVIT"OF CAlllk)RNIA <br /> FFNI`E:WNITR RILS URCES C'ONI"ROL I3()ARD <br /> TATA PROCESSING(MNTE?R <br /> P0.BOX 527. . <br /> PAR MOEJ ',CA 90-M <br />