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INSFRUMIONS FOR COMPLIMN6 FORM"Ir
<br /> GENE RAI,IN91*RUCITONS:
<br /> 1, One FORM '13"shall be completed for each tank for all NEW PERMI'VS,PFRMrr CIIANGES, REMOVALS and/or any
<br /> other TANK INFORMMION MANGE.
<br /> 2. This form should be completed by either the PERMTr APPI,ICANr or the IOCAL AGENCY UNDERGROUND TANK
<br /> INSPWFOR,
<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 ONIY ONE rMM*
<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 DESCRIPTION-COMPME AM.,HEMS-IF UNKNOWN-SO SPF",?Y
<br /> A. Indicate ownets 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(".ACME TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).
<br /> 11. TANK WYMNIS
<br /> A, 1. If MO'T'OR VEHIC11i FUI';I,,check box 1 and complete items B &C.
<br /> 2. if not mo,rOR V[lIIICI,F. IIUEt.,, 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 1 is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (C.hemical Abstract Service
<br /> number), if box I is NOT checked in O'k,
<br /> III. TANK COMSFRUMION-MARK ONii riTN ONLY IN Box A,B,c&D
<br /> 1. Check only one item in TYPE Oil SYSIEm,'TANK MATERIAL, INTERIOR LINING and CORROSION PRO'lVC`nON.
<br /> 1 If 0111ER,print in the space provided.
<br /> TV. PIPING INFORMIVITON
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable,
<br /> 2. If UNKNOWN, circle; or if 011II3R,print in space provided.
<br /> 3. Indicate the LEAK DL71,"CHON system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK.DI311".ION
<br /> 1. Indicate the LEAK DE,M]"C'.1710N system(s) used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMATION ON TANK PERMANENMY(TOSIA)IN MACE
<br /> 1. E_S'I1MA7rI.lD DAT.T.. IAST USED -MONIII/YEAR(January, 1.988 or 01/88).
<br /> 2. MIMMED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS'TANK FlIAT,l)WITH INEI;Vl',MA'I'F:.IUAI,? Check'Yes'or WO'.
<br /> APPLICANT'MUST`SIGN AND DKIT1111E FORM AS INDI(WM,'D,
<br /> I.N,5I`RIJC`nON FOR ITIF II)CAL 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:,pbtained 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 ago4ey prefers the State Board to assign the tank number, please leave it blank.
<br /> H'IS11M RESPONSIBILITY 01"1711111 IOCAI.AGENCY THAI'INSPI:X.'1`S ITIE FACILT'ITTO VERIFY ITIS
<br /> ACCURACY OF 7111?INIX)RMA110N, TILL?T.00AI.AGENCY IS RESPONSIBLE FORIIIE MMPIFI1ON OF 111E
<br /> *L)OCAI,AGENCY USE ONLY"INFO NITON BOX AND FOR FORWARDING OM!FORM "A*AND ASSOCIATI11)
<br /> DORM W(s)-10-17113,FOLLOWING ADDRESS.
<br /> SM17E 017 CALIFORNIA
<br /> SMIT WA71'ER RE-SOURCMS COMIROI,BOARD
<br /> C/o S.W.RL'Ps.
<br /> DATA PRO(MSSING CHNIER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
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