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AMOL, ANA"
<br /> INSTRUCTIONS FOR COMPLARIG FORM "13-
<br /> GENERAL
<br /> ' "GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3,Chapter 16,California Code of Regulationeri and sections 25286, 25287,ars , T
<br /> of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an LIST"operating permit.
<br /> 1. One FOR "B"shall be completed for each tank for all NEW PERMITS, 1F-"F IT CHANGES, O',
<br /> ALS and/or any other TANK INFORMATION FAT S.
<br /> 2. This farm should be completed by either the PERMIT APPLICANT or the , Ate,AGEENCY UNDER-
<br /> GROUND
<br /> t-
<br /> R U TANK INSPECTOR.
<br /> 3. Please 4ape or print clearly all requested inforrnati,°in.
<br /> Use a hard point writing instrument,you are making 3 copies.
<br /> Tank owners must submit e plat plan to the local agency showing the Ioo.s,4ik a of the k,y ST,s with respect
<br /> to buildings and lid arks 2711 { }(S)CCR].
<br /> S. Tank owners must submit documentation showing compliance . . stats reqtAre-
<br /> ments require-
<br /> mentsto the l cal a;lency for petroleum USTs IS711 (a){11)CCRji,
<br /> TOP OF FORM: MARK ONLY ONE ITEM ..
<br /> 1 a 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 Fi cilhj narrfe where the t nk is insta.,gid,
<br /> Ix TANK DESCRIPTION - COMPLETE ALL. EMS S - IF UNKNOW - SO SPECIFY
<br /> A. Indicate owners tank I - If there is a tank nUrhhar that is used by the owner to identify the tank(ex.
<br /> A773g),
<br /> , Indicate the nameon"the company=that rt? n f ctoro 'he tank(ex_ A MF TAT I FS)d
<br /> C. Indicate the year t sr=tank was installed ( . 5 9877)a
<br /> D. Indicate the t.._.air 1. r.,,c[t in n1ons exa.. ,t „
<br /> IL TANK °TENT
<br /> A. 1> IF MOT R,VEMCL , FUEL,a„ ,ick box i <..:r r£k is ..,.r.. ;ter,.., o&
<br /> 2. If not MOTOR,VEHICLE FUEL,check. '... s, e,W,i ..E.. box in section A and o plat items S&D,
<br /> Sa Check the a,,°'prop yrs box,
<br /> Check t.Pn oA g ...,TOS , 'I'r di.,f if .., 4.. aedked in A),
<br /> D, Print the chemical nerve of tie ha , ,roi, . t. rii.°° .).n „e stared in the tank and the ,A.S, , (Chemical
<br /> Abstract�
<br /> EIi. _ TANK CONSTRUCTION - MARK OINE �1t411 BOX A, S,
<br /> 1, Check only oz.s hagn {x TYPE O gA,. .. . 4ISATL�IA AN INTERIOR LINING � CORROSION .
<br /> PROTECTION.
<br /> 2. If OTHER,p °, d in the spore
<br /> 1. Circle Ask if .ilerove ground�.,.��,�°t, r`ur � -.0 , d circleb,th if applicable.
<br /> 2. If UNKNOVs` 6rcle"i or if OTH ER, print 41 spacemided,
<br /> 3. Indicate the m.,..,. K°.rt.:,T ECTIOt1 system ss,use d tY compy with the monitoring requirer ient for the piping.
<br /> - H TANK LEAK DFTrgCIF M:�
<br /> 1, Indicate the LEAK DETECTION system(s)used to cur°£T with the monitoring requirements for the tack,
<br /> I, INFORMATION (`;1,,J TA.Iii PFRMANEN:i,,.r$ t.t.F; .,,;t IN lel-.ACS
<br /> 1. ESTIMATED RATS LAST USED M �,°T JUY APian.-ant, 1988 or 31,138)
<br /> 2, ESTIMATED QUANTITY of 1 A 3 RDO. . 1" SUBIST k. a`1`.Y r, x:,r� ing in the tank(iii Gallons),
<br /> I
<br /> 1 WAS TANK FILLET WITH INMATERIAL?
<br /> T
<br /> TANK OWNER OR AUTHORIZED E REPRESS NT l"I�f`lr, I¢d i..+.„A$ _GN AND DATE THE FORM AS I l-
<br /> -i,,A IT D (see section 2711 (a)(1 3) CCR}
<br /> ,NSTR LICTION FOR THE LOCAL AGENCIES
<br /> The state underground steerage tank identification number is composed of the two digit-county number,trod three digit
<br /> wrtdiction number,the six digit facility numberand nd the six dig'11'tank numol er, The county,and jurisdiction numbers are
<br /> predefermiri"rid and can be obtained by calling the trd f913l 2.27-4303, 'the facility num rr us,,,t be the same as
<br /> shown in form"A" The tank number may be assigned by the local agency,however,this number most be numerical and
<br /> cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blink.
<br /> IT IS THE RESPONSIBILITY F THE LOCAL AGENCY 'THAT INSPECTS TPF FACILITY
<br /> 'TO VERIFY THE ACCU-
<br /> RACY
<br /> CU-RA Y 'OF THE INFOR00A"'TI N, THE Lt A AGENCY' RESPONSIBLE FOR THE COMPLETION F THE
<br /> �
<br /> `LOCAL AGENCY USF _` ,II.�.`'e INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND
<br /> YELLOW PISS. THE PINK COPY SHOULD SP RETAILED BY THE TANK OWNER,FT a
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