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r- - - - 7` -- <br />to <br />INSTRU(NIONS MR COMPLLrI1NG FORM 'Ir <br />Q <br />GENERAL IN,517RUCIIONS. <br />L One FORM 13" shall be completed for each tank for all NEW PERMM, ITR MT!'CHANGES, REMOVAI-S and/or any <br />other TANK INFORMA17ON (31 CII? <br />2, This form should be completed by either the PERM171'APPLICANF or the LOCAL AGENCY UNDERGROUND TAMC <br />INSPIX.71011: <br />1 Please type or print clearly all requested information. <br />4. Use a hard point writing ihs0ru4tient,yctu are making 3'c6pics, <br />1. 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 />I. TANK DESCRIPHON - COMPLU173 ALI. rMALS - IF UNKNOWN -SO SPIFFY <br />A, Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). <br />& Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG.). <br />C. Indicate the year the tank was installed (ex. 1987). <br />D• Indicate the tank capacity in gallons (". 25,000 or 10,(X0 etc.). <br />11. TANK CON`1TVrS <br />A, i. if marOR VEHICLE. FUEL, check box I and complete items B & C, <br />2, If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. <br />B. Check the appropriate box, <br />C. Check the type of MOTOR VEMIC11FUEL (if box 1 is checked in A). <br />D. 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 NOT checked in A. <br />HL TANK CONS`MUCIION - MARK ONE 1`111 ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, TANK MiVFERIAL, INTERIOR LINING and CORROSION PROTE(710N. <br />2. If OTHER, print in the space provided. <br />nalFuflpzI IIc! ti,rsV VDIZI <br />L Circle A if above ground; circle U if underground: and circle both if applicable. <br />2. If UNKNOWN, circle: or if OTIM"P, print in space provided, <br />3. Indicate the LEAK DFIT"C-11ON srtcm(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DisnxmON <br />1, Indicate the LEAK DETF.'CHON system(s) used to comply with the monitoring requirements for the tank. <br />I. i?srimxml) DATI, LAST USED - MON`n­I/YEA.R (January, 1988 or 01/88). <br />2. ES11MAITI) QUAN`1'rpY of HAZARDOUS SUBS`IANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INER`r MA'lr,,n-\T,? Check 'Yes' or 'NO'. <br />APPLICANF MUST SIGN AND DN11, '111F, FORMAS INDICNI19), <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. 'Me county and jurisdiction number,-, 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 number must be numerical and cannot contain an alphabet. If <br />the local agency prefers the State &,)ard to assign the tank number, please leave it blank. <br />rI'IS 'ITIS RESPoNslnuxry oi­nm wCAL AGENCY IIIAT INSPEC`fS ITIE FACILnT'110 VERIFY TIED <br />ACCURACY OFTHE INFORM/V110N. '111E LOCAL AGENCY IS RESPONSIBIE FOR 711E COMPI.FnON OF THE <br />ILOCAL AGENCY USE ONLY* TNFORM/V110N BOX AN[) FOR FORWARDING ONE FORM *A* AND ASSOCIK110 <br />FORM FOLLOWING ADDRFNS. <br />STIA31- OF CALIFORNIA <br />9DVI'E WYVIVR RIMURCES CON1701, 19)ARD <br />C/o &W.Iu-:P.S. <br />DiVIA PROCTSSING (;ATTER <br />P.O. TIO X 527' <br />PARAMOUN71', CA %M <br />00 0 <br />