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17- <br /> 1W.MUCUIONTS FOR(X.)MP1Jq1NG FORM'W <br /> GEN11RAL IN,'TrRUC'nONS: <br /> 1. One FORM "13"shall be completed for each tank for all NEW PFRmrn,Pl,,Rmrr CIMOES, REMOVAI-S and/or any <br /> other TANK INFORMMION CII ANGF, <br /> 1 `chis form should be completed by either the PERW'APPLI(ANFor the LOCAL AGEWY UNDERGROUNDTANK <br /> I NSP W 170 R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument, you are making 3 copies. <br /> I , <br /> TOP Of:FORM:'MARK ONLY ONE rruM <br /> 1. Mark an (X) in the box next to The item that best describes the reason the form is being complete <br /> 2. Indicate the ISBA oi-FaciI4 name where the tank is installed. <br /> 1. TANK DF-SCRIPHON-COMPLEI'13,ALI.rMMS-IF UNKNOWN-SOSTIfX317Y <br /> A. Indicate owners tank 11) #- 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 MF(.'i.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> 1). Indicate the tank capacity in gallons(ex.25,(X)O or 10,000 etc.). <br /> 11. TANK(MMIMS <br /> A. I. If MOTOR VEHICLE FUI L,check box I and complete items B& C. <br /> 2. If not NIOTOR VEHICLE FUEJ-,check the appropriate box in section A and complete items B& D. <br /> 13. Check the appropriate box. <br /> C. Check.the type of MOTOR VEHICLE FUEL(if box I is checked in A). <br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C-A,S.#. (Chemical Abstract Service <br /> number), if box I is Nor checked in A. <br /> 111. TANK CONSTMUCTION-MARK oNr,. nmiq ONLY IN 13OX A, I3,C&D <br /> L Check only one item in TYPE,OF SYSlT,%1.TANK MATUMIAL,INTERIOR LINING and CORROSION PROTE(MON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING,INFORMNITON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if 071'1IER,print in space provided, <br /> 3. Indicate the LEAK DE'I'E(.-l10N systern(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK 117AK DLrIIXTION <br /> 1. Indicate the LEAK DL7pECFION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMAMN ON TANK PERMANENMY CLOSE'.[) IN PLAM <br /> 1. E.911MA11 1) DAATI IAST USED-MON`D1/YEAR(,January, 1988 or 01/88). <br /> 2. ESFIMATi D OUA�MTI-y of HAZARDOUS SUBSTIANICE remaining in the tank(in Gallons). <br /> 1 WAS TANK 17111.hl)wrrm INE'RTMATERIAL? Check 'Yes'or'NO% <br /> APPLICANT MUST SIGN AM)Divnium FORM AS INDICWIUI <br /> IN91'RUCIION MR 771E LOCAL AGIT NCIE-S <br /> 'Ile state under round storage tank identification number is composed of the two digit county number, the three di-it jurisdiction <br /> number, the six digit facility number and the six digit tank numb(:r. The county all(]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 nuniOcr must he 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 /> ri'LS THE RFSPONSID11.11"Y OF 171E LOCAL AGSM Y'nim, TtAor-rry TO vE.mly ME <br /> ACCURACY OF'IJIE INFORMNHON, 'ME AGEN(.Y IS RESPONS11311, POR111E COMPLM1ON 017 77113. <br /> '1.,OCAL AGI WCY USE ONLY'INFORMA110N BOX AND IIOR FORWARD]NG ON17 FORM'A'AND ASSO(INYED <br /> FORM-B-(s)TO 1111, FOLLOWING ADDRESS. <br /> SDYM,OF CAIJFORNIA <br /> WIT ?p xl�x Im <br /> F! *A'9:,,R,R7�SO 1:RF7N MIPTJ V <br /> I.O. TIOX 527 <br /> PARAMOUNI7,(A%r,a# <br />