Laserfiche WebLink
0 <br /> fN,%'IRUCllONS 17OR COMPLE'UNG FORM-13- <br /> GENERAL INSTRUCIJON& <br /> I. One FORM "B"shall be completed for each tank for all NFw PERMITS,Py!,R3Hr CHANGES, REMOVAI-j and/or any <br /> other TANK INFORMATION CIMGF_ <br /> 2. This 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 /> Vi OF FORM:*MARK ONLY ONE MIAC <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 DF-SCRIVITON-COMPLUM1 All,rITOAS-IF UNKNOWN-SO SPInFY <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 CON`I1WI-',S <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 FUEL(if box:l is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract ,Service <br /> number), if box I is NOT checked in A. <br /> III. TANK C0N,`4RUCl1ON-MARK ONE rM-M ONLY IN BOX A,11,C&1) <br /> 1. Check only one item in TYPE OFSYSTEM,TAINTK MA7113RIAL, IINTIERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above around; 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 DETEX711ON <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON'TANK PERMANEW11M CMSIM IN PLACE <br /> 1. ESTIMATED DATE IA51'USED-MONTI I H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WrIll INERT MATERIAL? Check 'Yes'or'NO'. <br /> Appucwr MUST SIGN AND DATE 111E FORM&S IM)I(:A1'FJ). <br /> INSTRUCTION FOR'ITIE LOCAL AGIINCII-IS <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 maybe 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 /> rr IS im RilsPoNsIBiLITY owniii IA)CAL AGINCY 11IAl'INSPEC1'S'I1Hi FACILM TO VF.Rlry lint <br /> ACCURACY OF ITIE INFORMA710N. ITIE LOCAL AGENCY IS RESPONSIBLE FOR THE COMP11111ON 01711113 <br /> "LOCAL AGENCY USE om.y,uvoRmsnm Box AND MR FORWARDING)ONE FORMA'AND ASSOCIATED <br /> FORM'B'(s)TO 11 iFOLLOWING ADDRFN <br /> S. <br /> STAIV,OF CAI IFORNIA <br /> S17NIE WATER RESOURCE-S(X)N[*ROL BOARD <br /> C/o S.W.IULP.S. <br /> DATA PROCESSING CIMER <br /> P.O.BOX 527 <br /> PARAMOUN.1',CA 90723 <br />