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INSURUCIIONS FOR COMPLITIJW;FORM"I3" <br /> GENERAL INSI'RUCITONS- <br /> 1, One FORUM "13' shall be completed for each lank for all NEW PFRMrI`S,,PERM[rr CIIANGRS, RFMOVAUS and/or ally <br /> other TANK INFORMA'110N 01ANGIt <br /> 2. This form should be completed by either the PFS RW. I'APPIICANr or the LOCAI,AGENCY UNDER(3ROUNDTANK <br /> JN,SPEC7MR- <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 TIEW <br /> L Mark in (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 DFSCRTP`I1ON-COMPLITIT,ALI.nl]%S-IF UNKNOWN-So SPIU17Y <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. 1.987). <br /> D. Indicate the tank capacity in gallons (ex.15,0(X)or 10,000 etc.). <br /> 11. TANK CONIENIS <br /> A. 1. If MO'1'OR VEHICLE,FUI:T, check box 1.and complete items B&C. <br /> 2. If not MOTOR VEHICLE 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 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 Nar checked in A. <br /> III. TANK C0N,`MRUCI1ON-MARK ONE rru.m ONLY IN BOX A,B,C&D <br /> L Check only one item in'TYPE Oil SYSTEM,TANK MATERIAL, INTITRIOR LINING and CORROSION PROTECTnON. <br /> 2, If OTHER, print in the space provided. <br /> IV. PIPING INFORM)VIION <br /> L Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNY-NOWN,circle; or if 0111ER,print in space provided. <br /> 3. Indicate the LEAK DETEC'.I'TON systcm(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHIIIC'"ON <br /> 1. Indicate the LEAK DE`1T,,C`IJON system(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMA11ON ON TANK 1'ERMANEN17,Y CLOSED IN PLACE <br /> 1. ESIIMATI,,J) 1)/VrE I.AS17 USED-MON`rIT/YI!AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAxrrry of mZARDOUS SUBSIANCE remaining in the lank (in Gallons). <br /> 3. WAS"TANK FIL=LED W1111 INERT'MA'11,ILIAL? Check 'Yes'or'NO'. <br /> APPI.ICANI'mun SIGN AND DKI1111 IR FORM AS INDI(WIVD. <br /> IN9rRUCnON FOR 111H I)OCAI,AGENCIFS <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". 17he <br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain all alphabet. If <br /> the local agency prefers the State Board to assign the tank number, please leave it blank. <br /> II"[S'nfli RE�SPONSIBILI`17Y OF 171E LOCAL AGENCY'n1ATINSPIXJS ITIS FACIITI*Y TO VERIFY'H11? <br /> ACCURACY OF71IE INFORMAIION. '"IE LOCAI,AGENCY IS RESPONSIBLE FOR'I1I1?COMPIT'I7ON OF 111E <br /> 'LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM"A7 AND ASSO)CITID <br /> FORM'B'(s)TO 111E FOLLOWING ADDRE-Si. <br /> SFAT'E OF CALIFORNIA <br /> 9DVIV WA17ER R04SOURCE'S CON717ROL BOARD <br /> C/o S.W.11-Li P.S. <br /> DATA PROCESSING CENFFR <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 9q723 <br />