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INSIRUCHONS PCC)R COMPLVIING FORM'13' <br /> GENERAL INSTRUCIIONS- <br /> 1. One FOR;M "B"shall be completed for each tank for all NEW PE3 'S,PERMC.I'CHANGE S, RFMOVAI%and/or any <br /> other TANK INFORMATION(3IANGR <br /> 2. This form should be completed by either the PT .'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPI:�[Y)R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'TOP OF FORM:"MARK ONLY ONE 111sM' <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 DE:SC:RIVITON-COMPI.PrF.ALL rIZMS-It?UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank(ex.AD70789). <br /> B. 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(ex.25,(00 or. 10,000 etc.). <br /> H. TANK C:ON1T?NTS <br /> A. 1. If MOTOR VEHICLE FUE1,check box I and complete items B&C. <br /> 2.If not MO'I'OR VEHICLE FUEL.,check the appropriate box in section A and complete items B 8: D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICI.1 FUEL(if box I is checked in A). <br /> D. Print the chemical nacre 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 /> IDL 'TANK CON' RUCTION-MARK ONE rl'FM ONLY IN BOX A,E3,C&D <br /> 1. Check only one item inTYPE OF SYS'll...K'TANK MATI3,RIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OT 4ER,.print in the space provided. <br /> IV. 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 OTI-IER,paint in space provided. <br /> 3. Indicate the LEAK.DF..,TECIION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEr.IT7CTION <br /> 1. Indicate the LEAK DE"TEC TION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CI.AXSED IN PIACE? <br /> 1. ESTIMA1731) DATE LAST USED-MONIII/YE=AR(January, 1.988 or 01./88). <br /> 2. ESTIMATED QUANTI"T"Y of.HAZARDOUS SUBSIAN'CE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED tarn I INERT MATERIAL? ('heck'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 11IE?FORM AS INDICATED. <br /> INSTRUCTION FOR'111E 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. .IIhe 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". 'I`he <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 /> I'1'IS 111 RESPON.SIBILTIT OF TI-111 LOCM,AGI?NC Y THAT INSPE:C:IS TIIE FAC ILTIY TO VERIFY TIH! <br /> ACCURACY OF 111E INFORMATION. 'I.THI&.,O(;AI,AGF,N(:Y IS RISPON.SIEt1.13 I'OR TIIE C:OMPLLc'1ION OF TIIE? <br /> "LOCAL AGENCY USE ONLY"TNFORMA711ON BOX AND FOR FORWARDING ONE FORM"A"AND A,S,SO CINIT?D <br /> FORM"B'(s)TO ITHi FOLLOWING ADDRESS. <br /> STATI®OF C.ALIIRNIA <br /> SCATU WAIT*R RESOUII(:IN CONIR() ,BOARD <br /> D)A°I'A P OC11,SSING CV ITR <br /> P.O.IRYX 527 <br /> PARAMOUNT',(A 9Wa3 <br />