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INSIRUCIIONS FOR COMPLEVICY FO 'M <br /> GENERAL INSTRUCtIONS: <br /> 1. One FORM '13"shall be completed for each tank for all NEW PERMITS,PERMIT CILNNGES, REMOVALS and/or any <br /> other'TANK INFORMNIION CI CAL <br /> 2. This form should be completed by either the PERMI'I'APPLICANT or the LOCAL AGT,,N(-Y UNDERGROUNDTANK <br /> INSPECI'OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> ,rop OF vom.*MARK ONLY ow ITE w <br /> L Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK DESCRIMON-COMFIZITF.ALL ITEMS-IF UNKNOWN-SO SPFCIFY <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.15,000 or 10,000 etc.). <br /> 11. TANK CONTEMI'S <br /> A. 1. If MOTOR VEHICLE FULL,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 VFFIICLE 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.41. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in& <br /> 111. TANK CON5IRUC11ON-MARK ONE fl'LN ONLY IN BOX.A,11,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2, If OTHER,print in the space provided. <br /> TV. PIPING INFORMS11ON <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 DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK D911ICTION <br /> 1. Indicate the LEAK DETECTION syMem(s)used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANENTLY CIA)SED IN PLACE <br /> 1. E-S-11MATED DATF.I.AsT USED-MONT11/'YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of I-W. SUB91'ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITI I INEWI'MATERIAL? ("heck 'Yes' or'NO'. <br /> APPLICANT'MUST'SIGN AND DA11i 71W,FORM AS INDICATED. <br /> INSTRUCTION FOR'IIIH LOCAL AGI NCIMS <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)7.39-2421. 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 iocal agency prefers the State Board to assign the tank number,please leave it blank, <br /> r[AS171L RE-SPONSIDILM OFT11E LOCAL AGI ICY T[VVFINSPIX7S 711E FAC HX.I'Y'1'0 VERIFYTIJE <br /> ACCURACY OF 111E INFORMATION. TIIF LOCAL AGFN(`Y IS RINPONSIBLE FOR.'ITIE,COMP11T17ON OF'11IE <br /> *L00M.AGFNCY USE ONLY'INFORMA`11ON W)X AND FOR IX)RWARDING ONE FORM W AND ASSOC 1NI111) <br /> FORM-B-(s)'17O TIIE FOLLOWING,ADDRESS. <br /> 5rATE OF CALIFORNIA <br /> STSFE WNI'ER RESOURCES CONTROL BOARD <br /> C/o S.Wx.E Ps. <br /> DATA PROCESSING CMNITiR <br /> P.O.PA)X 527 <br /> PARAMOUNT,CA 90723 <br />