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INSTRUCUIONS FOR C;C➢ a 'I I *B"
<br /> 1. One FORM"13"shall be completed for each tank for all NEW ITR PERmu CHANGES, I C AI-,and/or any
<br /> otherTANK INFORNIN110N CHANGE
<br /> 2. 1 his form should be:completed by either the PE "r APP11CANpor the LOCAL AGENCY J C*RGROC T
<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 Er02 ; '&C&RK ONLY ONE EM"
<br /> L Mark an (X) in the bo next to the item that hest describes the reason the form is being completed,
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> I. TAN T! I1O --COMPTIrPE ALL NEMS-IF UNKNOWN-SO xPITILF'
<br /> , Indicate owners tank I l #-If there is a tank number that is used by the owner to identify the tank(ex,AI370789).
<br /> B. Indicate the narne of the company haat manufactur=ed the;tank (ex.ACME TANK FG.),
<br /> C. indicate the year the tank was instalted(ex. 1987),
<br /> . Indicate the tank capacity in gallons (ex.25,1 or 10,M)etc.).
<br /> H. TANK C O I'E E"Ea
<br /> A. T. If 14L()TOR VE'llICLE FLIi"L,,check box I and complete items i3&C;,
<br /> 1 If not MOTOR VEHICLE FUEL,L,check the appropriate box in,section A and complete items 13& D.
<br /> L3. Check the appropriate box.
<br /> C. Check the; type ofMOTOR VFI IIC,I,E 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 I is Nar checked in A.
<br /> EI. TANK C ON rRTJ1C nON-MARK ONE,rpFM ONLY IN BOX A,II,C&1)
<br /> 1. Check only one item in,rypE oi7 fs`ySTF II,'I,^NK MATERIAL, INkEi2ICli2 LINING and CORROSION i'ttC?`I'I^C'rION.
<br /> 2. If COWER,print in the space provided.
<br /> IV. Plt fNG II I#°CIR A`11 i
<br /> 1. Circle A if above around; circle L3 if underground,;and circle froth if applicable,
<br /> 2. If UNKNOWN, circic; or if OTHER,print in space provided.
<br /> 3. Indicate the LEAK E7ETEX` 1ON system(s) used to comply with the monitoring requirement for the piping.
<br /> V. `I"ARILS:LUAK DITI`C711CII
<br /> _-, l°-- Indicate the 11311K IJ1-1`1'I C.'JION system(-,) used to comply with the monitoring requirements for the tank.
<br /> VI. INFORMA11ON ONTANK PERMANFIV11,Y L.'Y.C)SIED IN PLACE
<br /> _ 1. I- lIATED Dt"'F;IAST tl"SP; -I~dOKFII/YF 1IL (January, 1998 or 01/88). _
<br /> 2. L;S11`INUVI :1.3 OUANTITY of HAZARDOUS SITITSTANCE remaining in the tank (in Gallons).
<br /> 3, WAS T2'%N K F"€l1TO VafHI INERT NI'ERIAL,;` Check 'Yes' or'NO'.
<br /> APPLICAN17 MYSF SIGN AND Dfa IV°Dili?FORM AS I DIC`w 'I 3I .
<br /> IN15PRU(NION 17011,11111 LOCAL AGLN(JES
<br /> '['he 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 number's 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 heal 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 /> 1STITE RESPONS11311XIT 017711111 LOCAL ffAC.IJ TC3 WiRIFY11TE
<br /> .`ACCURAC_' '"OF"IT , N1rC1" ATTC i9n `171E LOCAL AGENCY C IS RESPO SIL3I.E3 ISR`DIE,*C OMP11HUTO N 017/1111
<br /> 'LOCAL AGENCY iSE ONLY'Y'II EiT1. AIO X AND FOR FORWARDING ONE FOR "A'AND AS` C:Ix7IiD
<br /> ,5F/VtT OF CA11FORNIA
<br /> C/O Smx I?Ps.
<br /> DATA PROCM..I CI C.L= IIdZ
<br /> RO. BOX 527
<br /> PA C)UNI',CA 90723
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