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INSTRUC31ONS FOR COMP11NING FORN413' <br /> GENERAL IN,'1iT1RUC717ONS:- <br /> I. One ITOILM "B"shall be completed for each tank for all NL W PFR WIN,P1.1RMrl'CIIAN(;HS, R12AOVAI-S and/Or any <br /> other TANK INFORMA'RON C-11ANGE <br /> 2. 'Phis form should be completed by either the PI3RMTI'APPI1CAN7r or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC170R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you,are njaking 3 copies. <br /> TOP OF FORM.*MARK ONLY ONE 171:T.M* <br /> 1. Mark an (X) ih the boy,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 DF-SCRIV11ON-COMPIHrV.All.r11?,MS-HI UNKNOWN-SO SPFCIFY <br /> A. Indicate cAvners tank ID # -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%7). <br /> 1). Indicate the tank capacity in gallons(ex.25,0(xor 10,000 etc.). C/ <br /> 11. 'TANK(X)NIIWIN, <br /> A., 1. If MO'I'OR VEHICLE FUEL,check box I 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 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 1.is Nar checked in A. <br /> 111. TANK CONS'IRUCIION-MARK ONE rIT4M ONLY IN B()X A,B,C&D <br /> 1. Check Only one item in TYPE OF SYS"ITTM,TANK MA'ITIRIAL, IIN17ERIOR IINING and COTZROSION PROTECTION. <br /> 2. If O'HIER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTHER,print in space provided. <br /> 3. Indicate,the LEAK.T.)F.'['E(-17I(')N system(s) used to comply with the monitoring requirement for the p <br /> V. 17ANK 11AK DLFIIX:nON <br /> 1. Indicate the LEAK DF-IT3(.,'FION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INPORMA'11ON ON TANK PERMANIW11,Y CLOM0 IN PIACI? <br /> I. EsnmxmD DA'IT I.AS`I'USED-NION11-1/YEAR(January, 1988 or 01/8&). <br /> 2. ISl IKikig QUA1711'.1"y of I IA7ARDOUS SUBS-FANCE remaining in the tank(in Gallons). <br /> 1 WAS TANK FILLED WrIll INERT MATERIAL? Check'Ycs'or'*NO'. <br /> APPLICANT'hWqr SIGN AND DNI:L? IMI FORM AS INDICATED. <br /> INSFRUCIION FOR 711E LOCAL AGYN013% <br /> The state underground storage tank identification number is composed of the two digit county number, the three divit jurisdiction <br /> number,the six digit facility number and the six digit tank number. The County and jurisdiction numbers are predeter fined and <br /> can be obtained by calling the State Board (916)739-2421, The facility number must be the same as shown in form '['he <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 /> 117.17 LS THE RESPONSIBILITY OF IIIE LOCAL AGEN(Y IHAT INSPIX'I'S 71 IE FAC.'ILrrY TO VERIFY TILT? <br /> ACCURACY OF111F.3 INFORMATION. '1111 .,O(:AI.AGFN('YISR&SPONSIBI.lilk)RIIIE('OMPLMIONOFIIII- <br /> "LOCAL ACvl.!N(.Y USE ONLY*INFORMS11ON BOX AND 14OR FORWARDING ONE FORM'A'AND ASSOCl/V11 1) <br /> FORM'Ir(s)TO 11111 FOLIA)WING ADDRKSS. <br /> 91WIT,OF f:AIIFORNIA <br /> 7' <br /> 07)i,P,'PPT,IX)ART) <br /> CEN71'A <br /> 1',0,19)X 577.,�_. <br /> PARAMOUN17,CA WM <br />