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IN' ZIRUMIONS, J4OR COMPI.P'IING FORM *13'
<br />GENERAL INSFRU(7][I0NS:
<br />L One FORM "I3" shall be completed fox ;� h tank for all NEW 1"1".�R4TISPERMI'I'('IIAN(iKS, REM0VAI.S and/or any
<br />other'FANK INTIORMN11ON CHANGF.
<br />1 'rhis form should be completed by cither the PERMff APP11C1�01Vfor the I-D(AL AGf!N(.-Y UNDERGROUND 'TANK
<br />INSPEC'10R.
<br />3. Please type or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are making 3 copies.
<br />'1'OP OF 17ORM: "MARK ONLY ONE rI LM*
<br />I.- 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 />1. 'TANK DESCRI1`110N - (X)M1"L9im An. rnims - IF UNKNOWN - SO SPIXIFY
<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 />13, Indicate the name of the company that manufactured the tank (cK. ACMEIANK MFG.).
<br />C. Indicate the year the tank was installed (ex. 1987).
<br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.).
<br />11. "TANK (X)NITINN'
<br />A. 1. if VEHICH" FLA',"'L, check box 1. and complete item',' B & C.
<br />2, if not marOR VIjII(',LE FUE ' L, check the appropriwe box in section A and complete items B its D.
<br />R (,'heck the appropriate box.
<br />C. Check the type of MO'T'OR VEH7ICI.J., FUE1 (if box I is checked in A).
<br />1), Print ific ,;bemical name of the hazardous substance stored in the tank and the (',A.S.#. (Chemical Abstract Service
<br />number), if box I is NO'I' checked in A.
<br />Ill. 'TANK CONS17RUC*IION - MARK ONE r1TW ONLY IN BOX A, 11, C & 1)
<br />1. Check only one item in'I'YPE OF SYSIEM,'VANK MAIERIAL, INT'FRIOR LINING and CORROSION PRO'IE('110N.
<br />7
<br />2, If 01*11ER, print in the space provided.
<br />TV. PIPING INIA)RMA'110N
<br />1, Circle A if above ground; circle U if underground; and circle both if applicable.
<br />2. if UNKNOWN, circle; or if 0111FR, print in space provided.
<br />3. Indicate the 11.'AK system(s) used to comply with the monitoring requirement for the piping.
<br />V. 'TANK LMK DFI1X.'n0N
<br />t Indicate the LEAK I)jr:1-I'r,,C`I'ION system(s) used to comply with the monitoring requirements for the tank,
<br />VT. INFORMA11ON ON'IANK PI1,RMANE*NI1,Y 0.,OSED IN PIACE
<br />1. ES'HMAIED DA 11, LAST" USED - MOXHI/YEAR. (:January, 1988 or 01/88).
<br />2, 1.*�,,�DMNYED QUANIEN of HAZARDOUS SUIPSHANCL.' rema;ning in the tank (in Gallons).
<br />W 1
<br />3. WAS ].'ANK FILLED Wl'I'll INBC ' MA'11.RIAL? Check 'Yes' or 'NO'.
<br />Ail,pucAmr mtj%,r SIGN AND DA; IV 111E FORM XS INDICNIVI).
<br />INS*I'RUC!110N FOR 11113 LOCAL AGENCIEN
<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. 'I'lie county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (916)739-2421. 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 Board to assign the tank number, please leave it blank.
<br />TF IS 71111 RESPONSIBUXI"i 01111111 1,0(7U, m(;ny,a) VERIFY11111
<br />ACCURACY 011711111E INFORMN110N. 11111 LOCAL A('vlwC*Y IS RESPONSIBIJi FOR '111I3 COMPLIS110N OF "1'111:1
<br />"LOCAL AGENCY USE ONLY* INFORMATION BOX AND MR 17ORWARDINGv ONE FORM *A* AND A.W.)CIA7111)
<br />MRM -13"(s) 1101111.1, FOLLOWING ADDRESS.
<br />91'NIT! 017 (:AI.JFORNIA
<br />S1`XII! W`A7I'ER R0X)URCIIS C'ONrROL BOARD
<br />C/o S.W.I.l.1.4.P.S.
<br />DATA PROCESSING CHVIII,*R
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90-M
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