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� w <br /> INSTRUCTIONS FOR COMPI FnNG FORM"13" <br /> GENF,RAL INSTRUCTIONS: <br /> 1. One FORM "F3"shall be completed for each tank for all NEW PI?KNITS,PERMIT CJ.TANC31?x, KE2,9C3VA1:3 and/or any <br /> other TANK INF ORMA HON 01ANGF? <br /> 2. This form should be completed by either the PERMIT APPTIC:ANI'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <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 FORM:"MARK ONLY ONE ITEM" t-i <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or.Facility name where the tank is installed. <br /> 1. TANK DESCRII'IION-COMPLUFE All,ITEMS-IF UNKNOWN-SO SPF.MrY <br /> A. Indicate owners tank 11) # -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 /> H. 'TANK CON11WIS <br /> A. 1. If MOTOR VEHICLE FIA.,'1„check box 1 and complete items B&C. <br /> 2. If not MOTOR V13111C71,13 I^UFL,check the appropriate box in section A and complete items B& D, <br /> B. Check the appropriate box. <br /> C. Check the type of MO'.I`0R VE'llIC1.11 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 1 is NOT checked in A. <br /> TIL TANK C.ONFIMUCTION-MARK ONE 1'111M ONLY IN�BOX A,B,C&D <br /> L Check only one item inTYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If O'ITIER,print in the space provided. <br /> IV. PIPING INFORMAIION <br /> 1. Circle A if above ground; circle U it'underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK D11-TY3C110N systems) used to comply with the monitoring requirement for the piping. <br /> V. TANK I FAK DI?I'EC"ITON <br /> 1. Indicate the LEAK DETECT10N system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANF.NTI.Y C.I.OSF D IN PI.AC H <br /> 1. FSIIMATED DATE LA-51'USED-MONT1I1YEAR(January, PM or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SU1.3S`I'ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLET)Wrt'll INERT MA'II RIAL?Check'Yes'or'NO'. <br /> APPLI(ANT MUST SIGN AND DATE ITIE FORM AS INDIC:NIM. <br /> INSTRUCTION FOR TIIE 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 theotate Board (91.6)730-2421. 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 THE RESPONSIBILrIT OF THE LOCM.AGENCY 111N.1'INSPECTS 17I1.1 FAC:II PTY TY)VERIFY TITIN <br /> ACCURACY OF TIIE INFORMA`110N. TIIE I.00:AL AGENCY IS 111NPONSIBLE FOR'IIII:?COMPLETION OF'I1IE <br /> 'LOCM.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC.'INII?d) <br /> FORM'W(s)TO TIIE'FOLLOWING ADDRESS. <br /> STATE OF CAT.IFORNIA <br /> SIA17E WAl'ER RI:3SOURC ES CONTROL J30ARD <br /> C/O&W.F- P.S. , ° I '. f, t , <br /> DATA PROCT,S.STNG CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />