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<br /> INSTRUCTIONS FOR COMPLEW FORM 13"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16,California Codeof Regulations and sections 25283, 25287, and 2529
<br /> Of Chapter 5.7, Division 20, Health and Safety Code regular teak owners to apply for an USToperating p, ,n`,
<br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS, TTI°'aMIT CHANGES, REM
<br /> ALS and/or any other TANK INFORMATION CHANGE.
<br /> 3. This form should be completed by either the PERMIT"APPLICANT or he-,y.r SAL AGENCY,UNDER-
<br /> GROUND TANK INSPECTOR,
<br /> . Please type or print clearly all requested information.,
<br /> 4. Use a,hard point writing instrument,you are.making 3 copies.:
<br /> S. Tank owners must ����bmit a pint plan to the local agency showing the l t=o f theST with respect
<br /> o b ildiriga god l nark 12711 (a)(8)CCRI.
<br /> . ,Tank.owners must submit documentation r"mentation shote=ire mplia c with state fm nc l r ;.:;risibility require-
<br /> to to the lop °3oy for petroleum I STs[3711 (a)(1 1)CCR].
<br /> 'TOP OF FORM: MARK ONLY ONE it`If 1
<br /> 1, Mark an ( in the box next to the Item that boat describes the reason the fora is being completed,
<br /> 3. Indicate',the DBA or Facility,name where the tank is installed. b
<br /> 1. TANK K ES RIP T ION °- COMPLETE ALL, 51 S 1S KK IF UNKNOWN s SO SPECIFY
<br /> Indicate€w r is tank ID of If there is v tank number that Is used by the owner to identify
<br /> S 7S7Sf}.
<br /> S, Indicate the naris a. the company that rnanuf ctu ed the ko k(ex, ACME TANK MFG),
<br /> Irtdloafa the year the tank was=rrstIsd .e 1987). _
<br /> . Indicate the tank tar i :ions(ex,35,000 or 111'0,00Ac.�..
<br /> IL TANK CONTENTS
<br /> A. 1, IS IfoTEFf VE141 LE FUEL., check box 1 andoomplete,items S&C.
<br /> , If not 1 f° R VL I«II s:,LE FUEL,E .,.F r m t.,3° .gpp op I e box insecti n A and complete hares B&D°
<br /> S. Check the appr�o riatc;box.
<br /> S_ Check thP°° ; °.,w�1 zCLE Ft,El_,ft t cR,m ° is checked in °
<br /> S° Print the chemical l nerve of the I s a,c,.° substance star r in the teak and the C. .S, . (Chemical
<br /> Abstract Service number), tbox 1, is;,i�. -.I eck d in A.
<br /> III TANK CONS TRUCTION - MARK ONE Tr., °1 <1rlr.."r BOX A,
<br /> 1 Check oniv one,tern in TYPE ., TANK MATERIAL, INTERIOR LIMING and CORROSION
<br /> P TSCTI N.
<br /> : If OTHER,print in the space pr vidad
<br /> IV, PIPING INFORS T T IOC
<br /> 1. Circle"A" it above ground bUci "U"it nd r round; and circle b6th if applicable,
<br /> If I KNOW;a circle; or if OTHER, 7=I"=t in space provided.
<br /> da
<br /> 3. Indicate the LE i=tK DETECTION syslem(s)used to comply with the monitoring requirement for the'piping.
<br /> V. TANK LEAK DETECTiON
<br /> 1. Indicate the LEAK DETECTION T"ION yster (s used to comply with the monitoring requirernents for the tank.
<br /> VI. INFORMATION ON TANK ERNEN QTLY CLOSED I3 PLACE
<br /> 1. ESTIMATED DATE LAST USE -MONTH/ EAR(January, 1988 or 01153
<br /> <° ESTIMATED I,I ,NTPI� of HAZARD0U!:'1 SU STS NCE remaining in the tank(Ire Gallons),
<br /> 3, WAS TANK FILLED WITH INERT IMATERIAIU7 Shot>k 'es"or"No",
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE ORM AS INDI-
<br /> CATED [see section 2711 ('1I) CCR
<br /> INSTRUCTION FOET THE LOCAL E.. AGENCIES
<br /> The state underground storage tank identification number tuber is composed of the two digit co my number,the three digit
<br /> jurisdiction number,the alp digit facility number and the six digit tank number. The county and r.$risdiction numbers are
<br /> prad tar rind And can be obtained by calling the State Been.,,(313)2-27-4303:The facility number ;int be the setae as
<br /> shown in form'A". The tank number may be assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet. It., :e local agency prefers the State Board d to assign the tank number, please leave it blank°
<br /> IT IS THE ES NSI ILITYOF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF THE 11FORr,bMT°I N° THE LOCAL. AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE I.NL " INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN 71 HE ORIGINAL AND
<br /> YELLOW GOTPIE& 'THE PINK,COPY SHOULD SS RETAINED BY TICS,TANK OWNER.
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