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INSIRUCITONS FOR COMPLETING FORM-13- <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMI'15,PERMIT CHANGES; REMOVALS and/or any <br /> other TANK IM URMA37ION CHANGE <br /> 2 This form should be completed by either the PERMTr APPLICANT or the I.dCAL AGENCY UNDERGROUND TANK <br /> INSPI:C1'OR <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF In7RM:'MARK ONLY ONE 17177JW <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is boring completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK DFSC:RWIION-COMPI.I M All.l'I'F.MS-IF UNKNOWN-SO SPECIFY' <br /> A. Indicate owners tank 1D #- If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MF(i.). <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 /> 11. TANK CONI EN:IN <br /> A. 1. If MOTOR VEHICLE FUP.L,check box I and complete items B R C. <br /> 2. If not MOTOR VEHICI..I3 FUEL,check the appropriate box in section A and complete items B $; D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I 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 1.is NOT checked in A. <br /> III. TANK CONS.IRUCIION-MARK ONE ITEM ONLY 1N BOX A,B,C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MA7T:RIAI., INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA'T'ION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHT;R,print in space provided. <br /> 3. Indicate the LEAK DrgTCI1ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANTO LEAK DITIECIION <br /> 1. Indicate the LEAK DF'TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PERMANENIIY CLOSED IN PI.AC:E <br /> 1. E.S'11NINITl)DATE' L.A.S.'I'USED-MONTII[YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN111Y of IIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS'TANK FILLED WTI1I LtiEXI'MATERIAL?Check 'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DATP nm FORM AS TNDK;ATI:T). <br /> INSTRUCTION FOR"IIIE 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 local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT IS T11E RF.SPONSII3ILT17Y OF TILE LOCAL AGENCY'171A'I'INSPI­?X-I'S 17IE I-A(MT'I'Y 11)VERIFY 711E <br /> ACCURACY OF TIIE INFORMATION. TIIR LOCAL AGI?NCY IS RESPONSIBLE FOR'11IF COMPL1111ON OF TTIE <br /> %OCAL AGENCY USE ONLY-INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOCIN1111) <br /> FORM-Ir(s)TO TME FOLLOWING ADDRESS. <br /> SPATE OF CALIFORNIA <br /> SPATE WAT.7iR RESOURC71-S CON'T'ROL BOARD <br /> C/O s.W.l?Ei P.S. <br /> DATA PRCXTSSING CENIVR <br /> P.O.13OX 527 <br /> PARAMOUj Tr,CA 90723 <br />