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INS'TRUCIIONS MR C OMPLU G Irt) "IV <br /> GI?NMAL INSI'RUC:I'IONS; <br /> 1. One FORM "13"shall be completed for each tank for all N13W PERMTI'S,PF?IRMI'I'CIMCwFS, RF"sMOVAIS and/or any <br /> other TANK INFORMA717ON CHANGE <br /> 2. "Phis form should be completed by either the PFiR FPLIC'AN`f or the LOCAL AGI.NC'Y UNDERGROUND TANK <br /> INSPIXXOR. <br /> 1 Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrunienta you are making 3 cooiec. <br /> IOP OF IAC) RK ONLY ONE :M" <br /> 1. Mark an (X)in the box next to the item that best describes the reason Ilse form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DF?SCRIF"IION-COMPI,17LT AH.riv s-IIZ UNKNOWN-SO SPECIFY <br /> A. Indicate owners 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 tite tank was installed (ex. 11387). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 11. TANK CONI1WIN <br /> , 1. If MOTOR VEIIICLI" 171J,FL,check box I and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUl L,check the appropriate box in section A and complete items I3& I). <br /> B. Check the appropriate box. <br /> C. Check the type of MO'T'OR V14,11IC LE hUEL(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 NUTchecked in A. <br /> III. TANK CON9PRUC 11ON-MARK ONE ITEM ONLY IN BOX A,F1,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,1.-XNK MATERIAL,INTFiRIOR I..INING and CORROSION PRO'PEC'FION. <br /> 2, If O'I'III?R,print in the space provided. <br /> IV. PIPING,INFORMAI'ION <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 LLAK D),ITC"I7O`v system(s)used to comply-with the monitoring requirement for the piping. <br /> V. TANK IJ AK DI?"IT cnoN <br /> 1. Indicate the LEAK DEFFC1JON system(s) used to comply with the monitoring requirements for the tank. <br /> VF. INFORMA:I7ON ON TANK PERMANEN'I'I.,Y C.I.OSED IN PLACE <br /> 1. ESTIMATED DATFs IAST USI.D- MONTII/YEAR(January, 1988 or 01./88). <br /> 2. ES-11MATFI)QUAivrl`ITY of IW-ARI)OUS S1 B',S.O NCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLET) WITH JNERT MA'I iRFAL7 Check 'Yes'or'NO`. <br /> APPLICANT MUST SIGN AND DATE 111F3 FORM AS INDI(.A'1T;I), <br /> INSIIZUC TION FOR'I1IE LOCAL 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 obtained 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; howcver, this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State &-card to assign the tank number,please leave it blank. <br /> IT IS THE RE-SPONSTT31111"Y OWITIE LO(AL AGFINN `IIIAT INST11711l 17113 IrAC IUI'Y'1'O VERIFY 11111 <br /> ACCURACY OF'11TI3 INFOR PION. '17111,LOCAL AGENCY IS RESPONSIBU-41'FOR IIID COMPIJ-3I1ON OF 111111 <br /> 'LOCAL AGENCY USE ONLY*INFORMNIJON I1OX AND FOR FORWARDING ONE FORM W AND ASSOCIWIED <br /> FC)RM"F3"(s)TO'IT IE FOLLOWING ADDRIIS.S. <br /> S'TW IE OF CAI.FORNIA <br /> S17 IE WATER RII~SOUR(MS CONTROL BOARD <br /> C/O&W.I1I3 P.S. <br /> DATA PROCI SING CLWITIR <br /> P.O.BOX 527. <br /> PARAMOUNT",CA 9f M <br /> r <br />