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IN'sI'R(;(31ONS FOR C:OMP11flTNG T1)RM"II* <br /> GEWRAL INSI'R JCI IONS: <br /> 1.. One FORM "13"shall be completed for each ':ank for all NEW PV.1M1I'S,PERM:1"I'CIIANGF.S, RVMOVAI S and jc r any, <br /> other"TANK INFORMATION CIIANGII <br /> 2. This form should be completed by either die PERMIT APPI1CANt or the LC)CAL AGENCY UNDERGROUND TANK <br /> IN',5PECI"OR <br /> 3. Please type or print clearly all requested information. <br /> A. Use a hard point writing instrument,you ire making 3 copies. <br /> TOP OF FORM:*MARK ONLY ONE ITI3M* <br /> 1. Mark an (X)in the box next to the item ?:!v t')est describes the reason the form is tieing;completed, <br /> 2. Indicate the DBA or Facility name wbercr "'^e +.ink is installed. <br /> L TANK DESCRIPTION-COMPLE 1'E All.1711MS X tU'NKNOWN-SO!S1'Ek.3I?Y <br /> A. Indicate owners tank 11.) #-If there is r:tnro uember that is us,,d -v t.ae owner to identifv the tank (ex.AI370789). <br /> B. Indicate the name of the company that r ired the tank! 'If,TANK MF(i.)_ <br /> C. Indicate the pear the; tank was installed x:,. '), <br /> 1). Indicate the tank capacity in gallons (ex, =r lis c c). <br /> If. TANK CON ENI5 <br /> A, l.. If MO]IOR VIMICL.E FUIH1,check box i and complete items E3 & C. <br /> 2.If not Mo,rOR VI 1J1CLl Ft:FL,check the appropriate box in section A and complete items Il& 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE F'UI I.,.(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 N()T'checked in A. <br /> III. TANK CON917RUC3ION-MARK ONE ITEM ONLY IN PA)X A,B,C&D <br /> 1. Check only one item in TYPE OF SYSIFEM,TANK MATERIAL, INTERIOR LINING and CORROSION PRO'I"E:CT[ON. <br /> 2. If OT111:17, print in the space provided. <br /> IV. PIPING INFORMATION <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 DETEM. ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DFF:II7(711ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENT?Y CLOSI D IN PL.ACM <br /> 1. ESSIIMATED DAFT:I...AST USED-MON 1TI/YEAR(January, 1988 or 01/88). <br /> 2. £STIMA"FTI)QUANTITY of IWARDOUS SUBS-LANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILI.,ED WFFFI INEIn'MAATI RIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DIVIM'11113 FORM AS INDI(ATED. <br /> INSTRUCTION FOR TIIE LOCAL AGENC I S <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 (91.6)739-2421. The facility number must be the same as shown in form "A". 'IU <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 member,please leave it blank. <br /> rT'IS 11-113 RISPONSIBU I'TY OF 11IE3 LOCM AGI3N(Y'lltA"I`INSI'Fd TS'11113 FACILPTY TO VERII'Y 11II7 <br /> ACCURACY OF 11113 INFORMA'T'ION. 111E LOCAL AGENCY IS RISPONSIBIJI FOR 131E COMPLE17ON OF11W <br /> `LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM*A*AND A,S,xSOCINIT l) <br /> 17ORM W(s)1'0 TIIE FOLLOWING ADDRESS. <br /> WA'II OF CALIFORNIA <br /> "N A 1V WATER R11,SOU RC17S CONTROL BOARD <br /> C/O S.W.I?Ir P.S. <br /> DATA PROCESSING CENTER, <br /> P.O.BOX 52:7 <br /> PARAMOUNT,CA 90723 <br /> 0 • <br />