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-79P---W47 yww"� 741 <br /> INS`I'RUC7.I1ONS MR COMPI-JUING FORM-13- <br /> GENE IW.1NS1'RUC110KS-. <br /> 1. One FORM "B"shall be completed for each tank for all NM. PERMITS,PERMIT 011ANGF-S, RFMOVAI.S and/or any <br /> other TANK INF()RMA`I'I0N CHANGE. <br /> 2. This form should be completed by either the PERMIT'APPUCAMI'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 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE ITEM' <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 /> I. TANK DESCRIVIION-COMPLIN'Ll All,ITEMS-IF UNKNOWN-SO SPI3CH1Y <br /> A. Indicate owrteis tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <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.2.5,000 or 10,000 etc.). <br /> H. TANK CONTENTS <br /> A. I. If MOTOR VEHICLE FUEL, check box 1 and complete items B&C. <br /> 2. If not MOTOR 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 VIMICLE ITUEL(if box 1. 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 NOT checked in A. <br /> HL TANK CONI;I'RU(:I'ION-MARK ONE rIEM ONLY IN BOX A,11,C&1) <br /> 1. Check only one item in"TYPE OF SYSTEM,`TANK MATERIAL,, INFERIOR LINING and CORROSION PROT'ECT'ION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMAITON <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 LFAK DL,'TECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK II!AK DHW.0 ITON <br /> 1. Indicate the LEAK Dl-�TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANEMI1.Y CLOSED IN PLACE <br /> 1. ESTIMATITD DATE LAST'USED-MONI I H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INFIC11 MA'ITRIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST'SIGNAND DATE TIIE FORM AS ININCA719). <br /> INSTRUCHON FOR THE IOCAL 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. The 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". 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 /> IT is niERESPONSIBILITY OF TIIE I,OCAI.AGENCY`nIAFINSPWI',%'I11E FACItX1'YTO VERIFY'11111 <br /> ACCURACY OIVITIE INFORMAHON. TIIE LOCAL AGINCY IS RESPONSIBLE FOR 111E COMPIE11ON OF 111E <br /> "LOCAL AGENCY USE ONLY"INFORMA11ON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIKI`ED <br /> FORM-W(s)TO 11111E FOLLOWING ADDRESS. <br /> STATE 017 CALIFORNIA <br /> SFNIT!WA'I'TER RI�NOURC-VS CONI'ROL BOARD <br /> DATA PROCESSING C'EM113R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9072.3 <br />