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INSTRUCTIONS ION POP COMPLIRING FOS "B'
<br /> F L INSTRUCTIONS
<br /> Section,2711 of Title, ,Division 3,,Chapter 16,California Cade bf Regulations and sections 25266,25267,and 25269
<br /> of Chapt r 6,7,Division,2%Health and Safety Cod6 require tank owners to apply for ars LIST operating permit.
<br /> 1. Ohe FORM"13"shall be completed for each tonic for all NEW'PERMITS, PERMIT,CHANGESj' EMO
<br /> L d or t atte r d
<br /> INFORMATION F .
<br /> 2, i hip f hoiald p€ t by dither the PERMIT APPLICANT or the LOCAL AGENCY UNDER
<br /> I r � >
<br /> I p tT
<br /> " "tit° rift Kiri SIq t Info tirnn.
<br /> 4. L33 ted I paint meriting in trcarn nt,you are making,3 copies.
<br /> 5. T" n . n cnp unit pl€nt ra tot l a !d ria r hoc it t ladation df the UST's with resp
<br /> 6. T rtkx i rner cat t bruit ddc nrri ht tion hcn in ccrnnpl€ nco with t t 'financial responsibility r uire-
<br /> T OP OF FORMe,MARK, ONLY ONE ITEM
<br /> next to the item that bestdd dbes the reason the form is being completed.
<br /> 2:
<br /> Indioat theI)BA or Facilitynamb Where the tank, installed.
<br /> I>
<br /> TANK", DESCRIPTION pI F ,ALL ITEMS,� I UNKNOWN a SCS SPECIFY
<br /> Indicate ornr rnk'I.,; -If thereis&,tank norbr that is used by the owner tb idernti y the tank(ox.:
<br /> 7 9).
<br /> B. Indict `the rs rrie df the co pariy.'h t rnan6facturedthe tank(6x.ACME TANK MFG).
<br /> C. Indican tie,ye'arthetank was Installed(61; 1937).
<br /> D. Indicate the tank capacity In gallons(ek.25,000 or 10,060 etc.).
<br /> II. IK CONTENT'S
<br /> A. 6TVEHICLE'FUEL,check box t and complete item .
<br /> If not MOTOR VEHICLE,FUEL,dhheck the appropriate box in section A and complete items B&D.
<br /> . lick the, prrid ° box,
<br /> C. Check the type of MOTOR HIL FUEL(i box t i ch ccked In A)n
<br /> . . Print the Chem!
<br /> cal nerve of the hazardous substance stored in the tank and the .A. , .(Chemical
<br /> Abstract Service number),if sbox 1 Is NOT,chocked in A.
<br /> Ido- TANK TRIP TI - I{ ITEM ONLY IN BOX A, ,B,
<br /> 1, Check only'oneftorn in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR,LINING and CORROSION
<br /> PROLE$,I Na
<br /> 2. If T ,prat in the apace provided.
<br /> IV. PIPING INFORMATION
<br /> 1, irci M A"i a ground cirble"1"if undergroun ,'arnd circle batt if applicable. ,
<br /> 'if UNKNOWN- 'circle,or if OTHER, print in apace provided.
<br /> thdicalte,thetEAK DETtCtION y to O usedto dbmply with the monitoring requirement for the plprng,
<br /> V. TANK LEAK ET T N
<br /> 1; Indicate theLEAK,DETganoN rrt( used to comply with the'rrionitoring req iirerrtenta for the tank.
<br /> VL, INFORMATION ONT" PERMANENTLYCLOSED
<br /> " SA. TTI , THS (January, 19or 01/88-y"
<br /> 2. ESTIMATED QUANTITY of DOS UST
<br /> remaining in the tank(in Gallons),.,
<br /> 3. WAS TANK'FILLED WITH INERT MAT F I L2 Rock"Yes"or" o°a
<br /> TANK OWNER'OR' AUTHORIPRr:$ TATIVE�'MU, T SIGN AND DATE THEFOINDI.
<br /> CATS [see tion2711,(x)(13) CCRI
<br /> INSTRUCTION F THE, LOCAL AGENCIES
<br /> The state underground storage tank identification,humber is composed of the two digit county number,the three digit'
<br /> jurisdiction number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are
<br /> predetermined and can obtained y calling the Stto Board(916) 7@43036 The facility number must be the same
<br /> shown In fon `Ag. Thetank number may be assigned by the local agency,however,this number must be rnume I and
<br /> cannot contain an alphabet. I#the localagency prefers'the State Boatd to assign the t number,please leave it blank
<br /> IT 13 TIFF RESPONSIBILITY' F THELOCAL AGENCY THAT INSPECTS THE. FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE L I N OF THE
<br /> "LOCAL AGENCY USE LY". FORMATION TFf I C3L AGENCY AFI � L RETAIN T hI RAIL I`l
<br /> YPLL pi T' t Ft L RFT° I F y T H T l� R.
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