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9 0 <br />INSIRUCHONS FOR COMPLHIING FORM *B* <br />GENERAL IN',V1'RUC11ONS- <br />1. One FORM "13" shall be completed for each tank -for all NEW PERMITS, PERM.rr CIIANGF-S, REMOVALS and/or any <br />other TANK INF ORMA'11ON CIIANGE. <br />2. 'I'his form should be completed by either the PERMIT' APPLICANT' or the LOCAL AGENCY UNDERGROUND TANK <br />INSPECTOR. <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 rMW <br />I. 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 />1. TANK DF-SCRIVITON - COMPMrrE AIJ, r".S -11+ UNKNOWN - SO SPIX:IFY <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 the tank was installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />H. TANK CON117NIN <br />A. L If MOTOR VI II1CI.X1 FUEL, check box 1 and complete items B & C. <br />2. If not MOTOR VF. HICLE FUEL, check the appropriate box in section A and complete items B & 1). <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE FUEL (if box I 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 NOT checked in A. <br />HI. TANK CON91RU(n1ON - MARK ONE n_!EM ONLY IN BOX. A, 14, C & 1) <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br />2. If OTHER, print in the space provided. <br />IV. PIPING INF ORMA'17ON <br />L 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 DEFECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DITIVX-711ON <br />L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VL INFORMATION ON TANK PFRMANIWII.Y CLOSED IN PLACE <br />1. ES`1'IMA'I`FD DA'17E, I.ASI'USED - MON`FII/YEAR (January, 1.988 or 01�*. <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />1 WAS TANK III rJY_;D WITI I INI,'11<17 MA7IMRIAL7 Check 'Yes' or 'NO'. <br />APPLICANT MUST' SIGN AND DAT11111E FORM &S INDICNrED. <br />1.N,'1;I7RUCI'ION FOR THE 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; 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 />rF IS THE RU?TONSIBUX17Y OF'1711E LOCALAGINCY T1IK1'1NSPE(T15'11IE FACIIX17Y TO VERIFY 11111 <br />ACCURACY OF711F, "U?ORMNIION. 77fli LOCAL AGENCY IS RESPONSIBLE M41k111111 COMPtJq1ON OF'11IE <br />"LOCAL AGENCY USE om.y, INFoRmxnON BOX AND FOR FORWARDING ONE FORM *A" AND A.%OCIN1'ED <br />FORM 'B'(s) ix) -niE, FOL LOVaNG ADDRF_%. <br />STAT1.1 OF CALIFORNIA <br />'�TDVIM WAT[ilk RF SOURCHS CONTROL BOARD <br />C/0 Saw.F_11r.s. <br />DATA PROCESSING C1W1*ER <br />P.O. BOX 527 <br />PARAMOUNT, CA 90M <br />1� <br />