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INSTRUCTIONS FOR COMPI1r1`1NG FORM*13' <br /> GENERAL INS-17RUC11OW, <br /> 1. One FORM "B" shall be completed for each tank for all NE.-W PERMITS,PERM171'CHANGIN, RFMOVAI-S and/or any <br /> other TANK INF ORMA`110N CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI1CANr 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 IZORM: 'MARK ONLY ONE rll:M* <br /> 1. Mark an (X)in the box next 1:0 the item that best describes the reason the form is being completed. <br /> 2. Indicate toe DBk,or,Fqcifity name where the tank is installed. <br /> 1. TANK DESCRIP'11ON-COMPLE-17 AIL YI`EMS-IF UNKNOWN-SO SPECIFY, <br /> A. Indicate owners tank 11) # -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 MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex. 25,OM or 10,000 etc.). <br /> EL TANK CON [WIN <br /> A. 1. If MOTOR VEHICLE FUEL, check box I and complete items B& C. <br /> 2.If not MOTOR VEHIC1,13 FUEL, check the appropriate box in section A and complete items 13 &D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VETIICLE 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 Scrvi".e <br /> number),if.box 1. is NO'Ir I checked in A. <br /> III. TANK CONS171.1CITON-MARK ONE 1`111M ONLY IN 11OX A,B,C&D <br /> L Check only one item in TYPE OF SYSTEM,`TANK MATERIAL, INTERIOR HNING and CORROSION I'RoTE'CrION. <br /> 2. If OTHER, print in the space provided. <br /> IV. PIPING INFORMNIION <br /> I. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIE'R,print in space provided. <br /> 3. Indicate the LEAK Dfr][EC'110N system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK 11!AK DV.lWnON <br /> 1. Indicate the LEAK DETFCT'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PFRMANFNTIY CLOSED IN PLACE <br /> 1. DATE LAS.1' USED -M01VIII/YfAR(January, 1988 or 01/88). <br /> 2. ESTIMA11.1) QUANTITY of IIA7j1tDOUS SUBSTANCE remaining in the tank (in (Jallons). <br /> 3. WAS TANK 11, 1111111 D WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLi(:ANr MUST"SIGN AND DATE 7111i FORM AS INDI(WI`E1). <br /> INSTRUVIION FOR TILE IOCAL 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)7.19-2421. 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 /> ri,is THE RESPONSIBI[XIT 0171111;LOCAL AGENCY 114K.1'INSPEC'I'S 17111 FACIIJFY TO VERIFY 1111.1 <br /> ACCURACY 017111E INFORMATION. '111H IX)CAL AGENCY IS RESPONSIBIX,FOR 111E COMPLINION 017771E <br /> 'LOCAL AGENCY Usti ONLY" tNFORMX11ON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM'W(s)TO 11113 I?OI"WING ADDRESS. <br /> STXI'E OF CAIJFORNIA <br /> STATE WATER RESOURCES CONI'ROL BOARD <br /> CIO&W.E.E.P.S. - .' ; I I . I I_i , :. " , .0" '! '1 <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />