Laserfiche WebLink
w.. <br /> '" <br /> INSIRUCI70NS FOR COMPLE ING FORM'13' <br /> GENERAL INS]RUC11ONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMMS,PERMTL°CIIAI`GE-S, REMOVALS and/or any <br /> otherTANK.INFORMNIION ClVtNGI <br /> 2. 'Chis form should be completed by either the PERMIT APPLICANT 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 ONI..Y ONE 1`I13M' <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 DI3A or Facility name where the tank is installed. <br /> I. 'TANK DESCRIPTION-('OMPA?'.ALL n77,MS-117 UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) # -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. 1.987). <br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.). <br /> II. TANK CONTENIS <br /> A. 1. If MOTOR VEHICLE FUEL,check box I. and complete items B&C. <br /> 2. If not MOTOR VE1II'CLE FI..rI L,check the appropriate box in section A and complete items B by D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VIIIICLEi FUEL(if box I 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 1 is NOT checked in A. <br /> M. TANK CON' IFRUC`IION-MARK ONE rrEm ONLY IN 13OX A,11,C&D <br /> 1. Check only one item in TYPU 01'SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OT IBIZ,print in space provided. <br /> 3. Indicate the LEAK])ETEC"TION system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK 114AK DI?`IWnON <br /> 1. Indicate the LEAK DE TC71'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANEMMY CLOSED IN PIACI.; <br /> 1. L'911MA111) DATE:LAST USM)- MONI'II/YFAR(January, 1988 or 01/88). <br /> 2. fSTIMAIT,D QUANTITY of fIAyARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WITH INEiR''I'MATE RIAL? (:;hock 'Yes'or'NO'. <br /> APPLIC:ANI'MUS.]'SIGN AND DYED 711E FORM AS 1NDI(:A7"ED. <br /> INSTRUCTION FOR'I1IR LOCAL AGI:rNCIF_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 he 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 /> H IS T1113 RESPONSIBILTTY 017'1711,1 LOCAL AGENCY 1`HNT INSP1V.S'I1IE FACIII'IN TO VERIFY TIIE <br /> ACCURACY OF 11IE INFORMATION. 71113 LOCAL AGI?NC.'Y IS RESPONSIBII3 FOR 11I1?(X)MPI.I,IION OF'IIIE <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX ANIS FOR FORWARDING ONE]FORM"A'AND ASSOCIATED <br /> MRM'B'(s)TO T11E FOLLOWING ADDRESS. <br /> S`FNt`E OF C.ALWORNIA <br /> STAIR WNII?R RESOURCES C',ONIILOL BOARD <br /> C/O S.W.I?E.P.S. <br /> DATA PROCESSING C ENI'ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />