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INSTRUCnONS FOR V FORM*13" <br /> GENERAL U <br /> 1. One FORM W shall be completed for each tank for all NEW PL? F'S,PER rr CHANGHS, REMOVALS and/or any <br /> other TANK INPORMAITON CHANGE <br /> 2. This form should be completed by either the PERMa APPLICAN17 or the WCAL AGENCY UNDERGROUNDTANK <br /> 3. Please type or,print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3'copies. <br /> TOP OF FORM-'MARK ONLY ONE MN* <br /> 1. Mark an (:C)in the box 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 /> I. TANK DESK.T.IPPION•COMPLVIE All,r.I :, -IF UNKNOWNSPPXMry <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 /> B. Indicate the name of the company that manufactured the tank(ex.ACMETANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25, or 10,000 etc.). <br /> I.I. TANK CONIFN17S <br /> A. 1. If MOTOR VEIIIICLF FUEL,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 /> 11 Check the appropriate box. <br /> C. Check the type of 4FarORR VEHICLE E I~'UEL(if box I is checked in A). <br /> I), print the chemical name of the hazardous substance stored in the tank and the C:.A.S. . (Chemical Abstract S mice <br /> number), if box 1.is NOT checked in A. <br /> III. TANK CC)NS . UC'11ON-MARK ow mm ONLY IN BOX A,13,C&D <br /> 1. Check only one item in'I`YPE1 011 SYSTE K"TANK MAT IZRJAL,EVIE IOR 11 INN and CORROSION Tg1ZC1TEC"110N. <br /> 2. If OTI-Elk,print in the space provided. <br /> . PIPING INFORMA11ON <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIE R,print in space provided. <br /> 3. Indicate the LEAK I?I.:TIIC-11ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK I PAK DINEMON <br /> 1. Indicate the LFi.AK D ITCTION systems)used to comply with the monitoring requirements for the tank. <br /> INFORMATION ON TANK PFRMANFNI1,Y C;LOSFD IN PI..AC13 <br /> 1. ESTIMATED DA`IT7 LAST USFI)-Mf)NMI/Y AR(January, 1188 or 01/88). <br /> 2. ESTIMATED QUAIVIT17Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFITI I1VTR`I`MA`I'E1RIAL?Check`Yes'or'NO'. <br /> APPWANT MUST SIGN AND DATTI 1'HE IX)RM AS ININCAIT31 <br /> INKRUCMON FOR IIIE LOCAL AGENCIES <br /> "The state underground storage tank identification number is comprised of the two digit county number,the three digit jurisdiction <br /> number,the six digit facility number and the six digit tank number. `17he 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°° 1'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 /> I IS FFRESPONS11311117Y OF 717111 I:C3C'.AL AGENCY111AT INSPEMS°III.I:i FACII T1°"Y TO VERIFYTHE <br /> ACCURACY 017 11111 INFORM/070N. IIIE LOCAL A(WNC Y IS ^SPONSH3IsI 17011111E C:CI PIEN IC)N 01711113 <br /> "LOCAL AGFN U .&,ONLY'INFORMNITON BOX AND MR I ARDING ONE FORM"A"AND A&SOC3A'I11 <br /> FORM W(s)TO IWE F IaI,OWING ADD. : S. <br /> ST IE OF CAIMURNIA <br /> SVVF!W)Vll IC RIE" Ir RC°ITS(:ONFR 3L BOARD <br /> C/o&W I:?T?P S. <br /> D)VIA PII.C)C'.I=N.SING 0 IE <br /> P.O.BOX 527 <br /> PARAMOUN17,Cel <br /> r, � ,�, ,.o <br />