Laserfiche WebLink
INI;I'RUC,'nON,S MR COMPIHITNG FORM*W <br /> GEN11RAL I ;iER iCP1°I NS: <br /> I. One FORM "13"shall be completed for each tank for all NEW PIER I°S,PlitRivlrr CHANGES, REMOVALS and/or any <br /> either TANK INFORMA711ON CHANGI? <br /> 1 This forth should be completed-by either the PERMIT APP11CANT'or the LOCAL AGINCY ACTIN. UNDERGROUND TANK <br /> STMT' <br /> 3: Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making copies. <br /> TOP OF 4'ALNRK ONLY ONE P'111 <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 DESCRIPTION-COMPLETE ALL 11 S-IF UNKNOWNSPIWAZY <br /> A. Indicate owners tank TI)4 -If there is a tank number that is used by the owner to identify the tan ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank.(ex.ACME TANK MF(1.). <br /> C. Indicate the year the tank was installed (ex.1987). <br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000.,etc.). <br /> 11. 1' XI5 <br /> A. -1.If C)"I'C)pa VEHICLE FUEL,check box land complete items II& C. <br /> 2.If not MOTOR OR VEHICLE FUEL,check the appropriate box in section A and complete items Il&I). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE I UI?L,(if box I,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 NOI'checked in A. <br /> M. TANK C )N91'R 7 C)N,-MARK ONE ONLY IN BOX A,11,C&1) <br /> 1. Check only one item inTYPE OF SYS'I'E ,TANK MXI'ERIAL, INFERIOR LINING and CORROSION I'ItOTEC'I'ION. <br /> 2. If OTTIER,print in the space provided. <br /> IV. PIPING IATIO <br /> 1. Circle A if above ground;circle U if undergaround,and circle troth if applicable. <br /> 2. If UNKNOWN,circle;or if GIMER,print in space provided. <br /> 3. Indicate the LEAK L)lW`I"T ., C)N systems)used to comply with the monitoring requirement for the piping. <br /> V. TANK IEAK DITHM01ON <br /> 1._ Indicate the I.14AIC DIu ., 'I0N system(s)used to comply with the monitoring requirements for the tank. <br /> INFORMAITON ON TANK PERMANENILY C I ;i)IN PIACE <br /> 1. FSI-IMATED DATE 1AS I'USED-MO II I f YEAIC(January, 1988 or 01/�8). <br /> 2 IMA`1-*,D QUAYFITY of.IIA7ARDOUS SU13 17A CE remaining in the tank(in Gallons). <br /> 3. WAS TANK 17IL LED 'I'I I IN IT'i MATE LI L? Check'Yes'or'NC)'. <br /> AP'PP M'SIGN AND DWIMTHE FORM AS I P)IC A717 . <br /> S UC"IIC)N FORTIIE LOCAL AGPN0ES <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 (9111)739-2421.. The facility number trust 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 /> rI' S THE RESPONSIBII11YOFTHE I AGENCY'I wir iNspFkm,nm FACPP,IT E P Y TuR <br /> ACCURACY OF 1711 INMRMA11ON. 'I`TE LOCAL AGI C Y IS RENPONSIBLE FOR'THIP?COMM ION OF IIIEi <br /> AGINCY USE ONLY'INFORMN11ON BOX AND MR FORWARDING ONE FORM°A"AND AS` 10 <br /> MRM'W(a)TO ITIE 1UL1.C) INCT ADDRESS. <br /> ATP:OF CAIIMRNIA <br /> 1'XIIS WATFR RESOURCES C0N'r C)I BOARD <br /> C/o S .,Ps r, e <br /> DATA PROCM&SING C : 1 3TC <br /> P.O.PA)X 527 <br /> PARAMOUn CA 90723 <br />