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INS'I' UC"IIC)NS FOR CC)MPMFITNG FOR I3 <br /> GFNERAL INSI' U . 7ONIS. <br /> I, One FORM"13" shall be completed for each tank for all NEW PERMT.M,PFRMIT CHANGES, REMCAYAUS and/or any <br /> other'I'AN O 'ZION'CHANGE <br /> 1 This form should be completed by either the PERMIT 1PPLI N'I'or the LOCAL AGENCY JNIN:;ItGRO UNI:)TANK <br /> INSI" .II)It. <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 I'I7a <br /> 1. Mark an (N) 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 ITL.S I"1°IC)N-(X)MPLInE ALI,YFE S-II' C) -SC) Ia r 'I. <br /> A. Indicate owners tank II)#-If there is a tank number that is used by the owner to identify the tank(ex.AB7078 ). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMETANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D3 Indicate the tank capacity in gallons(ex.25,000 or 10, etc.): <br /> 11. TANK CC)N'1 ° I7; <br /> A. 1. If MOTOR VEHICLE:;FUEL,check box 1 and complete items B&C. ' <br /> 2.If not MOTOR VEHICLE:FUEL,check the appropriate box in section wand complete items B& L): <br /> M Check the appropriate box. <br /> C. Check the type of MOTOR VE HICLIA FUEL(if box.I is checked in A). <br /> I?. 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 /> IIL TANK C ONSTRUCaI'ION-MARK ONE ITEM ONLY IN BOX A,B,C>°&II <br /> 1. Check only one item in TYPES OF SYSTEM,TANK MA RIAL,INTERIOR LINING and CORROSION PROIT'1(7110N: <br /> 2. If CbnIEK print in the space provided. <br /> IV. PIPING I ITC)N <br /> L Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if C)"I`HER,print in space provided. <br /> 3. Indicate the LEAK D1 E'I:a.0 3'ION system(s)used to comply with the monitoring;requirement for the piping. <br /> V. TANK LEAK I IFI'E?.0]ION <br /> L Indicate the I.LAIC D13'ITICTION systent(s) used to comply with the monitoring requirements for the tank. <br /> INFORIANPION ONTANK PERMANIWI7,Y CLOSED IN PLACE <br /> 1. a"'TIMA'F'D DATE LAST USED m MO I/YEAR (January, 1988 or 01/88). <br /> 2. F—`i"I 'E"I D QUAN" r1'Y of IIA7AI2DOUS SUBSTANCE E remaining in the tank(in Gallons). <br /> 3. WAS TANK PILLED WITII INFRT M.A'E"Is I...B Check''Yes'or'NCY. <br /> Appu(:Aw musT SIGN AND I)XIM 7171H FORM A&4 INDICNIIED. <br /> INSI'RUCITON FOR717111i IA)CAL 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 numbem are predetermined and <br /> can be obtained by calling the State Board(116)739-2421, "The facility number must be the same as shown in form "A". The <br /> tank number may assigned by the local agency; however, this number trust 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 /> I'is 7Iw REsPoNsunury OF nul LOCAL AGENCY Y T SP x 17111 FACIII'1Y TO YI?R.IFY"111 E <br /> ACCURACY O `ITIE INT IC '110N. '1711E LOCAL AGENCY IS )NfSIBLF FOR 171E CCJ II:aITC)N OF 111E <br /> 'LOCAL AGI,NC Y USI?C) INFORIANITON BOX AND FOR FORWARDING CINE.?FORM"A"AND 'IED <br /> FORM-B-(s)TO 11111 FOLLOWING ADDRESS. <br /> ftTE OF CALIFORNIA <br /> 's;FJVIE WA711IR III-rS()UR :,S CO .°ROL BOARD <br /> C/C)smn F,-P.S. <br /> DATA PROCESSING C:E?N"IER <br /> P.O.BOX 527 <br /> 1'A f)UNI`,CA <br />