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IN91`R1JC;1 C)N s 17OR C OMPLEri. (I IAC) "I?" <br /> GENE MAL lb!,�;[`RUCHONS- <br /> 1. One FORM"13"shall be completed for each tank for all NEW PE$ 11,,PHRMrF CHANG1 5, REMOVAUS and/or any <br /> other'FAN INF()RMX11ON CHANGE <br /> 2, This form should be completed by either the,PE rF APPI 1 N1'or tilt LOCAI,AGENCY UNDERGROUND TANK <br /> INSP POR <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`OP OF R.)RM:"MARK ONIY C)NI?nim <br /> 1. Nark an (IC) 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 /> 1. TANK I)Ea 1'"ITON-COMPLUIM A11, l'EMS-IF UNKNOWN-SO S z 'I. <br /> A. Indicate owners tank II)# -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 cornpany that manufactured the tank(ex.ACME;TANK MF=G,). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> T7, Indicate: the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> 11. TANK C ONI13N'I S <br /> A. 1. If O1'0R V13I:IICI:E:1 FUEL,check box 1 and complete items II&C. <br /> 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B dr D. <br /> I3. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE'FUEL(if box.1. is checked in A). <br /> 13. Print the chemical name of the hazardous substance stared in the tank and the C.A.S. . (Chemical Abstract Service <br /> number),if box 1 is NOT checked in tA, <br /> 111. TANK CONS7.1'R JCITC)N-MARK ONE 117111M ONLY IN IXYX A,,I3,Ca&I) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, Ili°I"E RIOR IJNING and CORROSION PR0I1.iC`I1(.)N, <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA770N <br /> 1, Circle A if above ground;circle U if undergrounds and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 1 Indicate the LEAK I)E°T E,C I'ION system(s) used to comply with the monitoring requirement for the pipisng. <br /> V. TANK LEAK DE ,(NION <br /> 1. Indicate the LEAK D Ill:C`FION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMNIION ONTANK PI.iRMANIWIIY C A)SEI3 IN (I:i <br /> 1. ESTIMA1717.13 DATE LAST USED-MO I/YI!AR(January, 1988 or 01/88). <br /> 2. ESTI. TI I)QUANTCTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITIA INI RT MATERIAL? Check'Yes'tar'RIE)', <br /> I'PUC U87I'SKIN AND DATE ITIE?FORM AS 1 IC".AI <br /> INS UC HON E FC'I1IE 1. ` L 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()1()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 hoard to assign the tank number,please leave it blank. <br /> ri'IS°1 FIE RESPONSIBUX17Y()F`111)1 I Im AGENCY IIIAT SP I 111E F A,C'II1'C'Y TO VE3RHI`Y`1°11$ <br /> ACCURACY OTVITIE INFORM 11C)N. THE LOCAI.AGENCY IS )NSIEII..E?FOR°1'11!3 COMPLIHION OF 711)3 <br /> "I.() '" >AGIINC'Y USE ONLY"INF R 'I E)N BOX AND MR RWA INCE ONE FORM"A"AND&SSOCIATED <br /> 1 "IF(s)TU"I11I®FOLLOWING ADDRESS. <br /> A"E1I OF CA111FORNIA <br /> ai°A13? A'1U 12E> )URCII.S CONMROL BOARD <br /> Ci/r)S. .E.E-P.S. <br /> DATA PROCESSING(3:!NrFR <br /> P.O,BOX 527 <br /> PA OU I',CA <br />