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I fi `RUCLI'IC) S FOR COMPLMINGf3"
<br />GENERAL lNS`FRUC71TONS-
<br />;. One FORM "13" shall be, completed for each tank, for all NFW PERMTIN, PERMUCHANGIN, REMOVATS and/dr any
<br />otherTANK INFORMA711ON CHANGE
<br />2. This form should be completed by either the PERMyr MPLICANr or the LOCAL AGE U ER(.3 ,C)T .I,
<br />3, Please type; or print clearly all requested information,
<br />4. Use a hard point writing instrument, you are making 3 copies.
<br />UNI OF FORM. 'MARK ONLY CfNI: F' T1
<br />1, Mark an ) in the box next to the item that hestdescribes the reason tate form is being completed.
<br />2, Indicate the DBA or Facility name where the tank is installed.
<br />I. TANK DE.SCRTVIION -- COMMISPE ALL NEMS - IF U O - SPEUtry
<br />A, Iaadicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789).
<br />I3. Indicate the name of the company that manufactured the tank (ex. ACME IAN MFG1).
<br />C, Indicate the year the tarok oras installed (ex. 1987),
<br />1). Incfic.ate the tank capacity in, gallons (ex. 25,0hks or 10,000 etc.).
<br />IL TANK U)NMENI'S
<br />A. L If MOTOR VEMICLE Fr€. E'L, check box I and complete items 1:3 & C.
<br />2. If not :11C3TOR VEHICLE hi;t C, check the appropriate box in section A and complete items B & 1).
<br />F3, Check the. appropriate box.
<br />C, Check the type of MOTOR VLlIIICLI FUEL (if box 1 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 />runihcr), if laox 1 is {.)_I° checked in A.
<br />III. 'TANK CONTSP IJO] O - MAF NNE r11W ONLY INBOX A, 13, C° & is
<br />1. Cbe=ck orlhll orae sterol iaa '1'YP OF S`yS`I FM, `=ANK M..L'FERTAL, I:ti`IURIOR LINING and CORROSION I'FZOT C.TFION.
<br />2, If OTIIEIT, print in the space provided.
<br />IV. PIPING INFORMATION
<br />1, Circle A if above ground ircle U if underground; and circle both if applicable,
<br />2 III" grail ` c€g c r of O'1`IIF p., print in space provided.
<br />3, indicate the LEAK Eff,'ITE(7110N systems) used to comply with the monitoring requirement for the piping.
<br />", TANK IJ-UkK I)FPI`I CIION
<br />I. Indicate the 11"K UTFitTON systern(s) used to comply with the monitoring reruirenscnts for the tank.
<br />VT_NI,7 R%VI10N ONTANK Pl; t A f'N[I Y T,(XT3IT IN PLACE
<br />1. ESTIMATED 7r`Ld'F !Ar 51' 11'511:1) - MO\TlT3/YFAFe (January, 1988 or 0l/88'),
<br />2, ,EST TM,,%TI I) ()Iw`At ITFY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br />3. WAS T,h, PLUT-) t l) WITI I iNFyRT NLYIE RIAL? (,heck 'Yes' or 'No'.
<br />A pIJ(:ANP ,'�; FSIGPI AND DWITTI111 fiORM AS INDICIJVIED
<br />IN%' `IiI_;C7I.TC)N F(-)F( T1l1,1 LOCAL AGIEPJC°ITS
<br />p
<br />The state underground storage tank identificationnumber is composed of the two digit county number, the three digit jurisdiction a
<br />nuanlaer, the six taiga ta, lily number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br />can be obtained by cadhng the State Bosard. (916)739-2421. The facility number must he the same as shown in forma °A'. The
<br />hank rurrbcr racy beassigned by the local agency', however, this number must be numerical and cannot contain an alphabet. If
<br />the local aag ncy prefer the State- Board to assign the tank number, please leave it blank,
<br />rr IS "LLA RE-SPONSIBlIXI'Y OF °1 31? LOCAL AGF PJC Y 11IK[° INSP1f(-1Ti'ITIF3 FACILM110 VERIFY711E
<br />ACCURAC'Y OF MIF 3Ci1k,) A 1ON, 'J I ? )(AA , A N( ' IS I;SLC3 S 3L3f ISR I C I. I?I'IO OF `CFI
<br />'LOCAI, AG C' USE ONLY' INFOR A'11O Aims) FOR )1£ ARDING ONE 17O WAS AND ASSOCI I` D '
<br />FORM -Ir(s) TOTIM FaOILO UNG ADDRESS.
<br />SCA"IT; OF CALIFORNIA
<br />ISI]NI A`1Ts1( 1CF-NOU C F' C;CSMPROL BOARD
<br />C/o S,W Ly. t? p. s.
<br />F9 'I'A PROCUSSING C. IE
<br />Iia(). BOX 527
<br />PAF ? C)UNI", Cd1
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