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<br /> INS.17RUCIIONS FOR COMP11117ING FORM*13*
<br /> GENEMAL IN,%'I'RUC11ONS.
<br /> L One FORM "B"shall be completed for each tank.for all NEW PERM717IN PF.RMfI'C:IIANGHS, REMOVA[N inn jt,)r•any°
<br /> other TANK INFORMA'ITON CI
<br /> 2. 'Phis form should be completed by either the PERMn'APPLI(:AN1`or the LOCAL AC1UM Y UNDERGROUND TANK
<br /> INSI"EC'I'C)PL
<br /> 3. Please type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 collies,
<br /> TOP OF FORM:*MARK ONLY ONE rtEM*
<br /> 1. Mark an (X),in the bob next to the item that best describes the reason the form is being completed.
<br /> 2. Indicatb the IAX*oi'Facility name where the tank is installed,
<br /> I. "TANK DI.7SCRIV110N-COMP1.131.1?AI.I,rMMS-117 UNKNOWN-SO SPF"FY
<br /> A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank(ex.AB71?789).
<br /> B. Indicate the name of the company that,manufactured the tank(ex.AC;MI>TANK MIG.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> 1). Indicate the tank capacity in gallons(ex.25,(M or 10,000 etc).
<br /> 11. TANK(Y)N1T?NIS
<br /> A. I. If MOTOR VEHICLE 111111J.,check box 1 and complete items B & C.
<br /> t 2.7faiot.11 iTFOI,L 011CLE,FUEL,L,check the appropriate box in secticin A and complete items B& D.
<br /> B. (,'heck the appropriate box,
<br /> C. Check,the type of MOTOR VEHICLE I7UI;L(if box I is checked in A),
<br /> D. Print the chemical name of the hazardous substance stored in tete tank and the C.A.S.#. (Chemical Abstract Service
<br /> number.),if box 1 is NOT checked in A.
<br /> III. TANK MNS71RUMION-MARK ONE r17.W ONLY IN 13OX A,B,C& D
<br /> 1. Check only one item in TYPE OF SYI I '.M,'TANK MMI RIAL, I.NTF IOR LINING and CORROSION FRO I"CTION,
<br /> 2. If OTIII.71R,print in the space provided,
<br /> IV. PIPING INFORMA"17ON
<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 DETI-X711 >N system(s) used to comply with the monitoring requirement for the piping,.
<br /> V. TANK I1AK DIr'I'L7CI.10N
<br /> 1. Indicate the LI AK D1 I1C`I'IO systems) used to comply with the monitoring requirements for the tank.
<br /> VL INFORMAIION ON TANK PI:RMANI3NI1 Y CLO.SED IN PLACE
<br /> 1. FSTIMA'IT"D DA'IT LAST USED-MON,7DI/Yf,\R(January, 1988 or 01/88).
<br /> 2. ISSTIMATL'•D QUAIV`IT'X of IIAl=`MOUS SUBST"ANCIL remaining in the tank(in Gallons).
<br /> 3. WAS TANK FII,I,I I:)WIT11 INI R'I'MATERIAL? Check 'Yes'or'N0%
<br /> APPLICANT MUST SIGN ANI)DA'11?71II3 FORM AS INDIC X11 d).
<br /> INSTRUCTION FOR 111F..L.00,AL AGI:71NC7174 ,
<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)734-2121. The facility number must be the same as shown inform "A"- The
<br /> tank number may be assigned by the local agency; however, this number must he 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 /> rl'l r' I1IL?RESPONSIIIII.,TI Y C)F I1Ii?IACAI..AGI:zNC Y'11IAI'1NSPT:iC:T 'T1 TT?.FAC,,"11 rl Y'I O V1iR11'Y'I1IE
<br /> ACCURACX 0171111?INFORMAITON. 'I11I3 r.C)C AL AGF.N(.'1'IS RESPONSIBLE FOR TIIE COMPII?I'ION OF'I'HE
<br /> *IACAL AGIMN USE ONLY*INFORMWIlON, BOX AND FOR FORWARDING ONI?FORM*A*AND AS.SOCIA`111)
<br /> FORM*B*(s)1A I111i FOLLOWING ADDRI7&
<br /> 9IAI1?OF C:A1:117ORNIA
<br /> S1'A(7x WAAI'ER RI°= )LlR(7IS C;O "RO L JX),kR1,'
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<br /> P.0.MIX 527
<br /> r '' PARAMOUNI`,CA 90723
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