COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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INSTRUCIIONS FOR C.:OMPIJMNG )RM"13" GI?NERAL INSTRUC11ONS: 1. One FORM "13"shall be completed for each tank for all NEW PERMYF'S,PERMrr CTIA Geis, RINOVAI.S and/or any other TANK INFORMATION CIIANG1 2. This form should be completed by either the PERMFT APPLICANT or the LOCAL AGF?,NCY UNDERGROUND TANK INSPFfiTOR. 3. Please type or print clearly all requested information. 4. 1 Use a hard point writing instrument,you are making 3 copies. 'FOPC)F DORM:,"MARK ONLY ONE r113M" 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK I)MMUMON-C OMI 11TI1?All,171I MS-IF UNKNOWN-SO S'PFX31ry A. Indicate owners tank Il) #- If there is a tank number that is used by the owner to identify the tank(ex.AB70789). B. Indicate the name of the company that manufactured the tank (ex.ACME'TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,00()etc.), If. "PANIC C.'ONI73NTS A. 1.If MOTOR VIiF11CLE FUEL, check box'1. and complete items B&t C, 2. If not MOTOR VI':IIICLE FUEL, check the appropriate box in section A and complete items B &c D. B, Check the appropriate box. C. Check the type of MOTOR'VEIi1CI I FULL(if box 1 is chocked in A). 1). Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1, is NOT checked in A. 111. TANK CONSTRUCTION-MARK ONE rnN ONLY IN 130X A,13,C dI 1) 1.. Check only one item in TYP1,7.OF SYS 1,M,TANK MATERIAL, 'INTERIOR LINING.."r and CORROSION PROTECI:'ION. 2. If OTHER,print in the space provided. IV. PIPING INFORMA710N I. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,.print in space provided. 3. Indicate the LEAK 1)F M—FION system(s) used to comply with the monitoring requirement for the piping. V. 'TANK MAK DiTrFc17ON 1. Indicate the LEAK Df!,TEC1'ION system(s) used to comply with the monitoring requirements for the tank. V1. INFORMATION ON'TANK PERMANT NILY CI.,(XSED IN 1'I.ACE,, 1. ES'TIMA"IED DATE I..AS1'USED-MOhr:III/YEAR(January, 1.988 or 01/88). 2, I STIMATED QUANTITY of IWARDOUS SUBSfANC:E remaining in the tank(in Gallons). 3. WAS TANK FILLED WF'I'II INERT MA'IT'IRIAL?Check 'Yes' or'N(Y. APPIdCANT MUST SIGN AND DATA!1111?FORM AS INDICATED. INST'RUCT'ION FOR,11 IE LOCAL AGIINCII?,S The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421, The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. rI"IS 711E RESPONSIBIIXrY OF 11113 IACAL AGI:iNCY T11KI"INSPECIN'11113 FA(M TTY TC)VERIFY 17IL ACCURACY 0147111.1 INFzORMNIION. 111E LOCAL AGENCY IS RIMMSIBLF FOR 1111i COMPIHFION OF TIII:? 'LOCAL AGENCY USE ONLY"INF ORMA11ON BOX.AND FOR FORWARDING ONE FORM"A"AND ASSOCW7?D FORM"I3"(s)1.0.111H FOLLOWING ADDRESS. STA173 Of'(:A11FORNIA SIMV WIVIER RI?SOURCES CONTROL BOARD C/O S.W.F?F?.P.S. DATA PROCESSING CIUVn,?R P.O.13OX S27 PARAMOUNT,CA 9ffM