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I S 1'1t,LIC:I`1C) S Yk) "C OMPI 11NG ) I m "
<br />GENE RAI, IN,1fI`RUC`I10NS-
<br />1. One F()'RM "I3" shall be completed for each tank for all NFV PERMTOS, VE RMI`1' C'1 ANGIO , 12 MOVAIS and/or any
<br />other 'I`Ablik JMX)RMATION CHANGE
<br />1 'T is form should be completed by either the, Il1I LI' PPLTCt°NMor the (AL AGENCY NI'3ERGRC UND TA
<br />INSP1.t.C:. E Olit- ,
<br />1 " Please type or print clearly all requested information.
<br />4. Use a lard point writing instrument, you are making 3 copies.
<br />1'C)P OF I 1t . 'MARK ONLY () 17 I °It
<br />1. Mark an (X) iia -the twos next to the item that best describes the reason the fes€'am is being completed.
<br />2. Indicates the DIBA or Ilacility narne where the tank is installed,
<br />I. TANK 1)ES RIV1`E0N - C MPIZ1 1 A11, r,11I CS - IF UNKNOWN ` OWN - SC3 SPI" "Iff
<br />A, Indicateowners, tank ID # - If there is a tank number that is used by the owner to identify the tank (ex A1370789).
<br />#3. Indicated the name of the company that manufactured the tank (ex. ACME'1"AN h("r.).
<br />C. Indicate the year the tank was installed (ex. 1987).
<br />D. Indicate the tank capacity in gallons (ex, 2,5,(M or 10,000 etc.).
<br />II. TANK CiC)MIIWrS
<br />A. 1. if MOTOR VE111C„LTi FUEL,, heck boat I and complete items 13 & C,
<br />2. If not MOTOR VEHICLE' FUEL, check the appropriate box in section A and complete itenss T3 & T.B.
<br />13. Check t'he appropriate box.
<br />C . ` Check the type of C)`FOR VI"HIC 1 T FUEL (if box i is checked in A).I). Print the chemical mare of the hazardous substance stored in the tank and the C`,.II.S,#, (Chemical Abstract Service
<br />nuniber), if box 1 is NOT checked in A,
<br />III, TANK C':) t 17RU, 111 - MARK ONE MIM ONLY IN I, X tiro 13, C& I)
<br />1. Check only one item in TYPE OF SY9I'E1 , T'ANK MA"YERIAL, INTERIOR LINING and CORROSION fl"18011t0110:N.
<br />2. If OTTIER, print in the space. provided,
<br />IV. PIPING JNPORMIVrION
<br />L Circle A if above ground; circle U if underground; and circle both if applicable.
<br />2. If UNKNOWN, circle; or if 0'1111.,"R, print in space provided.
<br />3. Indicate tire LI:,IC DE111;C:"110Nsystem(s) used to comply %ith the 'monitoring requirement for the piping,
<br />V. 'I" IC LFAK 1)I 11a.0 ,11C:I i
<br />1, Indicate the LIa,� 1 EME"C'I`TO systetaa(s) used to comply with them unit€wring requirements for the tank.
<br />1. INPORIAN110N ONTANK PEIRANTI '17,Y C"LOSIM IN`T"1. CH
<br />1, E,101M71TE) DA111 LAST CS I?; - O FT/"YI,AR (January, 1,988or 01/89).
<br />2, I I'S 1'I 11"1771) QuAmfrry of HAZARDOUS SUBSTANCE, remaining in the tank (in Gallons).
<br />3, WAS TANK FILLED WI11I Check 'Yes' or 'NO'.
<br />PP1JC ° U,4rf SKAN AND D 11VII113 FORM Fifa INDI(:iFiIVD.
<br />I 1JC"1"10N FORTHE IDCAL AGENCIMS
<br />The state underground storage tank identification number is composed ofthe two digit county number, the three digit jurisdiction
<br />number, the six digit facility number and the six digit talk number. The county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State 13oard (916)739-2429. 'I'he facility number must be the sante as shown in form "A". 'Be
<br />tank number may be assigned by the tical agency; however, this number must be numerical and cannot contain an alphabet. If
<br />the local agency prefers the State 13ctard to assign the tank number, please: leave it blank,
<br />ff IS 31111 2&SPONSIBILYff OF 11111 1LGI- C Y 111AT INSPlX3S 11113 F C tIXI"Y"'M VERIFY 311,11
<br />ACCURACY CY C)Ea °1 1H INFORMKI10N. 71117 IXXAL AGENCY 119 R&SPONSIBLE FOR 1,1 COMPI.PrION OF 11113
<br />*LOCAL AGI C"Y USB C) " INPORMN11ON BOX A 13 MR IX)RWARDING ONI I FORM 'A' AND ARSOCIA111D
<br />FORM -13-() TO "11111 F011,0WING 1)1) I'LSS,
<br />,S'lW113 OF CAI JFORNIA
<br />K I' "1'11 WNII,,R RKSO RC :S C ONTROL BOARD
<br />C'>/) :x. .111? ps.
<br />DATA P1 O03 .I CI (>131V "1 t
<br />P,O. IX)X 527
<br />P OUN'r, CA 9YM
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