COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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Iii I. RUC�I IONS FOR COMPLFFfNG FORM "I3" GENERAL IN . II .: Ca 1. One FORM "I3" shall be completed for each tank for all NEW PERMrM P1jRMrr CHANGES, RFMOVALS and/or any other'FANK IN17ORMA77ON C:IIANGF- 2. This form should be completed by either the PER I'r APPUCAN17 or the LOCAL AGENCY UNDERGROUNDTANK INSPECFOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are snaking 3 copies. ° 7OP OF PO ONLY ONE i 1. Mark an (5C) in the box next to the item that best describes the reason the form is being conspleted. 2. Indicate the TUBA of Facility name where the tank is installed. I. TANK Iiia ON - CPIPI AI..I. n'P UNKNOWN SPFJMPY A Indicate owners tank ID - If there is a tank number that isusedby the owner to identify the tank (ex, AII7{37€39). B. Indicate the name of the company that manufactured the tank (ex. ACM T'ANIC t r(.i<.). C. Indicate the year the tank was installed (ex. 19£37). D. Indicate the tank capacity in gallons (ex. 25,000 or 10, etc.). ,p II: 'FANK CONIMNI'S A. 1. If MOTOR VEHICLE, FUEL, check box 1 and complete items 13 & Cr. 2. If not MOT'OE2 VEHICLE I"UE?L, check the appropriate box in section A and complete iters I3 & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A). Di , 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 NO':l"checked in A. III. TANK CONM` J IIC)N ® MARK ONE flijM ONLY IN BOX A, 13, C & D L Check only one item in TYPE OF SYSTEM, 'PANIC MATERIAL, INI`ERIOR LINING and CORROSION PROTE:CI'ION. 2. If OTHER, print in the space provided. . PIPING IM70RMNIION 1 Circle A if aboveground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if OTHER, print in space provided. 3. Indicate the LEAK DE'17EC ION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK D111 3 ON 1. Indicate the LEAK DE`I7 C TION system(s) used to comply with the monitoringrequirements for the tank. . JNFORMAIION ON TANK PERMANEW17LY C:I:.O.S IN PLACH L ESIINIA'FED DATE, I -AST USED - M0N"IIJ/YE?lAR (.Ianuary, 1.95£3 or Ol/Ai3). 2. E.SI`IMA`rED Qj..1AN'FITY of IIA7ARDOUS SUBSFANC E remaining in the tank (in Clallons). 3. WAS TANK 14ILLE D Yt rIll INE'.RT NV%'I:ERIAL? Check 'Yes` or'NO'. APP11CAMr MUSr SIGN AND DATI:i `I`I-II? ITOR )IC:A71-. INST�RUC-FION ITOR71113 LOCAL AC`FNCIIa 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 (915)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 member must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, p€ease leave it blank. 17F IST 113 RESPONSIBII.XrY OF ITIE LOCAL AGiNcy,nisr INSPI Is TIm FAn ,f .yro vF-Rwymm ACCURACY OF'171113 I ]ION. °I`EIE LOCAL AGENCY IS-SPONSIBI.F. 1101117111-4 C°.OMPLUITON OIT11113 "LOCAL AGENCY I STI ONLY' INFORMATION BOX AND MR FORWARDING ONE FORM °A" AND A. ` ,C]NIT0 FO "I3"(s) TO -nIE FOLLOWING ADDRESS. I'E OJT CAHFORNIA "7EKII? WA'IImIi IiI IIS , ItC)I ° : AILI) C</C) S.W.L+ Ig P S, DATA P Mi SING CI:r .II?I2 P.O. BOX 527 PARAMOUNT,CA