Laserfiche WebLink
INSTRUCTIONS FOR COMPIZITNG DORM"13" <br /> GENERAL IN:sIRt-IC11ONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMrI'CITA.NGOS, RFMOVAIS and/or anv <br /> other'TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LO AI.,AGENCY UNDERGROUND TANK <br /> INSPWFOR. <br /> 3. Please type or print clearly all requested information. <br /> d. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM: "MARK ONLY ONE rT w <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 /> L TANK DESCREMON-WM.PIJ?W,ALL r112AS-W UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tan€: (ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the sink was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 1I. TANK CONTENTS <br /> A. 1.If MO'T'OR VEHICLE FUEL,check box'� and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUEL.,check the appropriate box in section A and complete items B& 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUIEL(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 1 is NOT'checked in A. <br /> M. TANK C ONS1'RUCHON-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1.. Check only one item in'TYPE OF SYS'T'EM,TANK MATERIAL, INI'LRIOR LINING and CORROSION PROTECI'IOM <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER, print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LAK DETE(711ON <br /> 1. Indicate the LEAK DTiI'ECI ION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA7.11ON ON TANK PE:RMANIWIl Y CT CASHI)IN PLAC.I? <br /> 1. I-.STIMATED DATE IASI'USED-MONI1i/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTI II INERT MATERIAL? Cheek'Yes`or'NO'. <br /> APPLICANT MUST SIGN AND DATE TtIE FORM AS INDICATED. <br /> INST'RUC`TION FOR TIIE LOCAL 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(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 Board to assign the tank number,please leave it blank. <br /> rl'IS THE RESPONSIBILH'Y OF 111E LOCAL AGENCY THAT INSPECIN 111E FACILITY TO VERITY 11111 <br /> ACCURACY 017111F.INFORMAITON. TIIE LOCAL AGENCY IS RESPONSIBLE FOR TME COMPLI3I1ON OF 11IE <br /> *LOCAL,AGENCY USE ONLY"INFORMAITON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM"B"(r TO TIIE FOLLOWING ADDRFS& <br /> STN1'E OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.I?E?P.S. <br /> DATA PROCESSING C ENHIR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA <br />