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INSIRUC17ONS FOR COMPLInING ICM"1?
<br /> CyFNI!RAI.INS rRUC`n0NS-
<br /> L One FORM'13"shall be completed for each tank for all NEW ISI RMrl'S,PERmrr CHANGES, REMO 'AI S and/or any
<br /> other TANK JNFORMA'nON CHANG&
<br /> 2. This form should be completed by either the PEM .Cl APHICANT or the LOCAL AGENCY UNDERG ROUND 17ANK
<br /> INSPECI'Olk.
<br /> 1 Please type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> Toi 01,,FoRM.-,*AARK ONLY ONE rl'FM'
<br /> 1, Mark an(X)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 DIT-SCRIP110N-COMPLIKIM A11,r1l3MS-IF UNKNOWN-SO SPIY(3M
<br /> A. Indicate owners tank 11) #-If there is a tank number that is used by the owner to identify the tank (ex.A1370789).
<br /> M 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`(cx.25,000 or 10,000 etc.).
<br /> ff. TANK CONIUMn'
<br /> A, 1,If O'FOR V12111CLE IVEL,check box I and complete items B& C.
<br /> 1 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 V11.111CLE FUEL(if box 1. is checked in A).
<br /> 13. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Suzvice
<br /> number),if box 1 is NOT checked in A.
<br /> 111, TANK COS MUCIO N-MARK ONE 1`11M ONLY IN'ROX A,B,C&D
<br /> 1, Check only one item in TYPE Of'SYSTEIM,'I'ANK MATERIAL,INTERIOR LINING and CORROSION I`RamcnON.
<br /> 2. If 011JE1T..print in the space provided,
<br /> IV. PIPING INP0RMKnON
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable,
<br /> 2, If UNKNOWN,circle; or if 01TIER,print in space provided.
<br /> 3. Indicate the LEAK DE�-.1`1-010N system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK.D1117FC17ON
<br /> 4. Indicate the LEAK DETECI 110N system(s)used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMA110N ON'FANK PERMANIW11,Y CLOS111)IN PLACE'
<br /> L RSI1N4NI'ED DATELAST TJSI:D-MON`l1I/YFAR(January, 1998 or 01/88),
<br /> 2. ESTIMATED QUANTIVY of R.�ZIRDOUS SUW4FANCII remaining in the tank(in Gallons),
<br /> 3. WAS TANK FILLED WITH INFI;Cr MATERIAL? Check 'Yes'or'NO',
<br /> AppucAmr musr SIGN AND DNI M 11111 FORM AS INDICNMO.
<br /> M13`MUC`nON`FOR'nIE LOCAL AGINCIM
<br /> The state underground storage tank identificatiorl 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 local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> IT IS 11111 RESPONSIBlIXFY OF 111,13 1A)CAL AGENCY]1IAT INSPW: 17S'IIIE FACILITYTO VER11'Ynill
<br /> ACCURACY OF ITTH INFORMNITON. '111E LOCAL,AGINCY IS RINPONSIBIM FO1II'F[11, COMPL1N OF 11111F,
<br /> 'LOC-AL AGENCY USE ONLY'INFORMN110N 11OX AND FOR FORWARDING ONE]FORM W AND ASSOCIN110
<br /> FORM-13-(s)IX)ITTE 1?011X)WTNG All) &S.
<br /> 91WIM,OF CA11FORNIA
<br /> S 'ES C "BOARD
<br /> FAIT!WNIER RWU
<br /> TRC ONTRDL
<br /> C/o W.W.I:,-El P.S.
<br /> DXIA PROC=ING C17NfER
<br /> POC 527
<br /> PARAMOUNI7,CA 90M
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