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INSI`RUC 11ONS FOR C()MPUU G IN) 'I3" <br /> GENERAL IN5('IL (,7110NS- . <br /> 1. One FORM "13"shall be completed for each tank for all NI3W PERMrI`S,Pl?RM1°E'01ANGES, RI:3MOVAIS and/or any <br /> otherTANK INIURMAT7ON CHANGE. <br /> 1 'This form should be completed by either the PERMU'APPLICANT or the LC)CAL AGFNC Y UNI ERGRO€.7ND TANK <br /> 1 Picase type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP 01?R)RM: 'MARK ONLY ONE TI MM' <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 /> 1. PANIC D0WR11Y170N-(X)MPLI?1'1.X AI.L n FMS-IF UNKNOWN­SO SPIX-IFY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMI_i TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1937). <br /> D. Indicate the tank capacity in gallons(ex. 25,0W or 10,0(X)etc.). <br /> II. TANK(X)NIENI'S <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEIIICLE FUFL.,cheek the appropriate box in section A and complete items B & 11 <br /> B. Check the appropriate box. <br /> C:. Check the type of MarOR V111IECLE FUEL,(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 /> III. TANK C:ONSI'RUC'11ON-MARK ONE 1"11W ONLY IN BOX A,I3,C&D <br /> L Check only one item in TYPE OF SYST'F...M,TANK MATFRIAL,IN'T131t10R LINING and CORROSION PROTF,ClION. 3 <br /> 2. If(YI'ILE , print in the space provided. <br /> IV. PIPING INFORMNIION <br /> Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 1 If UNKNOWN,circle; or if 0111EIR, print in space provided. <br /> 3. Indicate the LEAK D1:"II C"IION sy:;tem(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IXAK I HI"1?C"nON <br /> 1. Indicate the LEAK DFFE3C'I'I0N systems) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA'I7ON ON TANK PERMANFMILY CLOSED IN PI.ACX <br /> 1. ESTIMATED DX11, LAST USED-MON TII/YEAR(January, 1988 or 01/88). <br /> 2. ESIIMAT .iD ofiANTE'L'Y of IIAT,ARDOUS SUBSTANCE:;remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WITH INERTMA'ITRIAL? Check 'Yes'or'NO'. <br /> APPLICANT'MUS17 SIGN AND DX113'111.FORM AS INDICKIT11 <br /> INS'TR.UCCION FOR111E LOCAL AGENC"II?S <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&lard to assign the tank number,please leave it blank. <br /> rT IS`['[1:13 RE:rSPONSIBI11I"Y OF 11113 LOCM.,AGENCY"THAT INsp fs TIIE FAC'ILnT'i'0 VERIFY 71111 <br /> ACCURACY OF 11W INFORMATION. THE LOCAL AGFNC Y IS RISPONSII3I,Ii FOR 11113 COMPII:IION OF THIS <br /> 1.CJ " AGENCY USE ONLY"INFORMXIION BOX AND FOR FORWARDING ONE FORM W AND ASSOCEAIED <br /> FORM"13"(s)TO 11IF F011.0WING ADDRE,S& <br /> S11 IE OF CAI II ORNIA <br /> SFI IE WAIER RESOURCRS CONI'ROL BOARD <br /> C/O S.W.11.E.P.S. <br /> DATA PROC��ING C_'I3NTER <br /> P.O.13OX 527', <br /> PARAMOUNT,CA 900 <br />