Laserfiche WebLink
INSI'RUCIIONS FOR COMPLIAG FORM "Ir <br />GENERAL INS'I'RUCITONS: <br />1. One FORM 13' shall be completed for each tank for all NEW PERMITS, PERMIT C-11ANGF.S, REMOVALS and/or any <br />other TANK INFORMNIION CIIANGE- <br />2. This form should be completed by either the PERwr APPLICANT or the IOCAL AGENCY UNDERGYROUNDTANK <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 rll2vf* <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 D13A or Facility name where the tank'is installed, <br />I. TANK DRSCRIP`I'TON - COMPII3.1'E ALL ITEMS - IF 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,OW or 10,000 etc.). <br />IL TANK (X)NTI?NIS <br />A. 1. If MOTOR VEHICLE FUEL, check box 1. and complete items B & C. <br />2. If not MOTOR V171 IICLE FUEL, check the appropriate box in section A and complete items 11 & D. <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE 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 C0Nt;FRUC!11ON - MARK ONE rI'EM ONLY IN BOX A, 11, C & D <br />1. Check only one item in 'TYPE Of' SY51'EM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br />2. If OTIIER, 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 OTHER, print in space provided. <br />3. Indicate the LEAK DF',TECI`ION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK I.EAK DUII?UIION <br />1. Indicate the LEAK DEI-EC'.17ION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PERMANENII.Y CLOSIA) IN PLACE <br />1. ESI1MATF',D DATE LASTUS17D - MONIJI/YfAR (January, 1988 orol/88). <br />2. ESTIMATED QUANTITY of JIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS "TANK FILLED WITH INERT' MA'11,71UAL? Check 'Yes' or 'NO'. <br />APPLICANI'MU!;f SIGN AND DKI1.111IF FORM AS INDICATEID. <br />INS7I7RUC'n0N FOR'nIE LOCAL AGIN0KS <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 />n, IS TME RESPONSIBILITY Of' "IE LOCAL. AGI3N(7f THAT INSPI"S'11111 FACILrVy'110 VERIFY 11]13 <br />ACCURA('Y OF TIIE INFORMNIION. 111E LOCAL AGENCY IS RESPONS11311! POR THE COMPI1..r170N OF 111E <br />*1)0".. AGENCY USE ONLY' INFORMA110N BOX AND I:UR FORWARDING ONE FORM "A! AND ASSOC'IA'TED <br />FORM 1111.1 FOIJ OWING ADDRESS. <br />STK1'E OF CALIFORNIA <br />STNIII WA111,R RFISOURCES CONI'ROI. BOARD <br />C/o S.W.I?n P.S. <br />DATA PRO(MSSINCY CENIT-,R. <br />P.O. PDX 527 <br />PARAMOUNT, CA 9(Y123 <br />