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INSTRUCTIONS FOR COMPLITrING FORM"13" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "BI shall be completed for each tank for all NEW PERmnN. PERMIT ci]ANGFS, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. '17his form should be completed by either the PERMIT"APPLICANI'or the LOCAL AGENCY UNDERGROUND TANK <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 ITEM* <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 DESCRIPTION-COMPLETE All,r1FAS-IF'UNKNOWN-SO SPM'[I?Y <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 /> 1). Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> H. TANK CONIVR-M, <br /> A. L If MOTOR VEHICLE FUEL,check box I and complete items B & C. <br /> 2. If not MOTOR VEHICLE 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 MEL(if box 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 NOTchecked in A. <br /> HL TANK CONSTRUCTION-MARK ONE 117EM ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in'I'YPE OFSYSTEM,'TANK MATE-'RIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,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 DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE'T'ECTION <br /> L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ONTANK PERMANEN17LY CLOSE:D IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBS'I'ANCE remaining in the tank (in Gallons). <br /> FILLED 3. WAS TANK F LLED WHII INERT MATERIAL,? Check 'Yes'or'NO'. <br /> APPLICAN37 MUST'SIGN AND DATE 11111 FORM AS INDICATED. <br /> IN,I;MUCIION FOR"IE 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 /> nr is iiiii 1113SPONSIBILITY ON TME LOCAL AGENCY THAT"INSPECTS111E FACIIlTY TO VERIFY IME <br /> ACCURACY OF ITIE INFORMAIION. ITIE LOCAL AGENCY IS RESPONSMIJ!FOR TI IE COMPLIM ION OF11113 <br /> "LOCAL AGENCY USE ONLY"WFORMAIION BOX AND IUR FORWARDING ONE FORM*A*AND ASSOCIATED <br /> FORM W(s)1`0 FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> SFJVIM WATER PJ,'—';OUIWF-S COWROL POARD <br /> CiO <br /> DATA PROCESSING CIWI`ER <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 90723 <br />