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INSIRUCAIONS FOR COMPtHIING FORM*13" <br /> GE,,NERAi.INsrRuclioNs% <br /> L One FORIN-1 "B" shall be completed for each tank for all NEW PERMITS,PEIRMIT CI-I.ANGF-S, REMOVAI-S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PFRMrI'APPIlCAN1'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument, you are making <br /> copies.. <br /> 'MP bF'PO kM: -4ARX­ONI.'-Y`ONE TMM- <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Jnd7catvth%I)13A-prI,7,1ici1ityname where the tank is installed. <br /> I. 'TANK DF-SCRUY171ON-COMPLU111 All,TfVMS-If'UNKNOWN-SO SPIMI-IFY <br /> A. Indicate owners tank,11) #-If there is a tank number that is used by the owner to identify the tank (ex.AB70789). <br /> B. Indicate the name o"I the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> 1). Indicate the tank capacity in gallons(ex.2.5,000 or 10,(X.)1 etc.).' <br /> H. TANK(X)NIIWI',S <br /> A. I. If MOTOR 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&1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEMICLE FUEL(if box 1. is checked in A), <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number),if box I is NOTchecked in A. <br /> 111. TANK CON!;IRU(.`11ON-MARK ONE 171-EM ONLY IN BOX.A,B,C&1) <br /> 1. Check only one item in TYPE OFSYSTEM,TANK MATERIAL, rN71'ERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,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 OTHER,print in space provided. <br /> 3. Indicate the LEAK Df','1TEC-H40N sy-stem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DET X'IION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANIWII.Y CLOSED IN PIACI? <br /> 1. ES17IMNIT.1) DATE I.AS`I' USED-MONTI]/YEAR (January, 1988 or 01j88.). <br /> 2. ESTIMATED QUAN71TY of liAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK F11,114,I) WITIT INEWFMAITMIAL? Check 'Yes'or'NO'. <br /> Appucwr musr SIGN ANDJ.)A1`E'IlIIl FORM&S INDwNrun <br /> INS'.MUC11ON FOR THE LOCAL AGENCII-TS <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)739-22421. 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 contaitfan alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> rr IS THE REsPoNsfBHJI'Y OF111E LOCAL AGI.NCY T11KIANSPECIS-111E FACH.1717Y 1*0 VERIFY ILII; <br /> ACCURACY OF 11IF INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBLE FORnIE COMP11117ON 01717113. <br /> "LOCAL AGENCY USE ONLY"INFORMA`1`10N BOX AND FOR FORWARDING ONE FORM*A*AND ASSOC ANtI7.0 <br /> FORM-11-(s)TY)II-II;FOLLOWING ADDRESS. <br /> STA11i OF CALWORNIA, <br /> DATA PROCESSING Cl,:NFER <br /> P.O.BOX 527 <br /> PARAMOUNI7,CA 90723 <br />