|
II49I .LJ>.TC)NS POR C,'OMPLI I CI IAC) 'I3w
<br /> GENERAL INSI'Rt1. ONS;
<br /> 1. One FClltM"13"shall be completed for each tank for all NEW PTIR ni,PE RIV[rr CHANGE-S, REMOVALS AES and for any
<br /> other'EANK INMRMXnON C lIANGF-
<br /> 2. `I'his form should be completed by either the PER rrAM,JC' °or the.LOCAL AGIENCfy UNDE RGROl7 EI 71ANK
<br /> INSPECMR.
<br /> 3. Please type or print clearly all requested information.
<br /> , Use a hard point writing instrument,you are snaking 3 copies.
<br /> 1OP OF FORM:*MARK ONLY ONF MIM
<br /> I. ark an(X)is the box lent to the item that best describes the reason the forma is being completed.
<br /> 2, Indicate the DBA or,Facility name where the tank is installed.
<br /> I, TANK DIS RIE'11ON-COAlit IE AI,L,TIMMS-III UNKNOWN-SO SI F
<br /> A. Indicate owners tank;II) # -If there.is a tank number that is used by the owner to identify the; tank(ex.AB70789).
<br /> 13, Indicate the name of the company that manufactured the tank(ex.ACME: "T`Aa`NK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 7187).
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 14,W0 etc.).
<br /> It 'PANIC CONITNIN
<br /> A. 1, If MOrrOR V13.111CIAi FUld,,check box 1 and complete items B& C.
<br /> 2.If not MOTOR VE11ECLIH I`U11,, check the appropriate box in section A and complete items R& D.
<br /> I3. Check the appropriate box,
<br /> C. Check the type of MO'TC712 4'I.,I11C:I,I>FUEL(if box 1 is checked in A).
<br /> I), Print the chemical narne of the hazardous substance stored in the tank and the C,A.S. .(C'hernvcal Abstract Service
<br /> number),if box I is NO'S'checked in A,
<br /> III. 'fA NS°rRU('IION-14 ARK ONE Y17EW ONLY )K As 13,C& D
<br /> 1. Check only one item in TYPF OF fS'YSIf; 1,'I°A?'IK bINT tIAL,IN`I'ERJOR'HNIN(3 and 00,R OSION Ia13C1'l V(71710N,
<br /> 2, If OTHER Pont in the space provided.
<br /> IV. PIPING INIIORMKIION
<br /> 1, Circle A if above ground; circle U if underground;and circle; Paoth if applicable.
<br /> 2, If UNKNOWN,circle; or if 011IF3p,print to space provided.
<br /> 3. Indicate the, LEAK DE;I1:sC I'l0N systcm(s)used to comply with the monitoring requirement for the piping,
<br /> V. 'FANK 11AK DE,113.C'r1ON
<br /> 1. Indicate the LFA€{DEFECTION I C1°ION system(s)used to comply with the monitoring requircmerns for the tank.
<br /> I, 17 °LIC)N ON'I'ANK PERMANEIVIIN CLOSE t)IN PIACI?
<br /> 1. 1A'T`E D L)A°IE, LAST USED-MONFIIfYFA12(.lanuary, 1. or 01/88).
<br /> 2. FS"I7 A D QUANa"ITIN of HAZARDOUS SL BSFAISC E remaining in the task(in Gallons),
<br /> 3. WAS TANK FILLED W111IIiS"1 E1'I'MA'l I EIIAL2 Cheek'Yes'or'NO'
<br /> Appucywr MUSrSIGN ANIS DNIE`I'IIE?FORM AS D A'I'01
<br /> I NI LIC`J7ON Ik)R 711E,LOCAL AGEN017—S
<br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction
<br /> - number,rile six digit facility number and the six digit tank.number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by ceiling the Stela Board ('916),739-242L 'Fhe facility nurntier must be the same;as sj,.ovaa in form 'A', 'flee
<br /> tank number may be assigned by the kxA agency; however,this number must be numerical and canno. contain are alphabet, If
<br /> the local agencyprefers the State Board to assign the tank number,please leave;it blank.
<br /> I`IS TEII?RESMN`3JB11XI'Y 01111111,LOCAL L AGENC 11IMF INSPI7(7n'pE I IS?FACHYFY,110,' I7 1 'llIE
<br /> ACCURACYOF T1 I INFOR ATEON. 11111 LOCAL AGENC S RLNSPON>SII3LE FOR.37113 COMPLU.TION OF"IIID
<br /> *U)CAL AGFWCY USI, ONLY'INIsORMA711ON BOX AND FOR FORWARDING ONE FORM!110 AND ASSOCINITO
<br /> R *13"(s)°M 17111 FOIJOWING AT}I)RlT%
<br /> 917VIE OF C-AIMIORNIA
<br /> 91A71M WNI R RIa` URC HS ONI`ROL BOARD
<br /> C/O S.1Y ,I?P.S
<br /> LATA PROC KSS"ING CENTEIR
<br /> P.O.BOX 527
<br /> PARAMOUNT',CA WM
<br />
|