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INtrRUC711ONS IaOR(XWP1aiF DICE FOR*'
<br /> GENE.RAL FMITa1 'C i>waNS,
<br /> 1. One FORM"13"shall be completed for each tank forall NF ER q Pi,,RMrr CHANGES, REMOVAUS and/or any
<br /> other'` K INFORIMA11ON CHANGE
<br /> 1 "file form shouid be completed by either the I'IIRU"I'I C AN17 or the U)C' I.,AGENC Y UNDERGROUND'I'ANK
<br /> IsSpC'C`1°C�
<br /> .a,
<br /> Please tyfa or print clearly all requested information,
<br /> , Use a hard point writing instrument,you are making 3 copies,
<br /> 'I'OP OF FORf0i*NLARK CI °I,r ONE CI W
<br /> 1. Mark an "I-Y) 1n tfrc Iron next to the stem, that best describes the reason the form is being completed.
<br /> 2. In icalk, hc DBAor Fstcdj1 nuntt,-,v ere the tank is installed,
<br /> I, '..TANK I'E-SCRIVI"1tf -(X00't_UIE 1VLL TIVMS-IF UNKNOWN OW -SO STIR-Il r "
<br /> A. araa;icatc s)=yne is tang H # If then, is a tank number that is used by the owner to identify ilea.Yank(es.AB70789).
<br /> , lttr caoL the r.is,W 4 the company that manufactured the tank(ca. ACNIF'>" ANK MFG,).
<br /> )
<br /> C. Indlo`at the}ca. .,t °:atrs Was:insu fitcd (or. (d8 ).
<br /> 1), 1s.;.c etc ._.e w:a capa6ty in garilorr»fax. 25,0WWY or I0,0 (3 Dict).
<br /> I. 'I A K til l ETS I� �
<br /> W5, ft.€'t;?I k11s1, _._, IC ill„ .lt,;c =>ox and cot
<br /> items I1 C'.
<br /> R 1t not VE1I1x,a.13 p1...,E1.,check the appropriate box in section rk and complete items 1,..& D.
<br /> . Check the ,.,i rr hriwe lrox.
<br /> C,
<br /> Clhcck Inr i pe or Nr 1I'SIC VEHICLE 1 E FUEL I (if box W is checked in A),
<br /> D" Print the c'rea i,..a< narse of the hazardous substance stored in the tank and the(,A,S4, (C hernicat Abstract Service
<br /> nu saber), rs bo,, 1 is\fp ci ecked in A
<br /> III. 'I'ANK C0*zd,1�F`R%UC.°I1ON..MARK ONE,rlVMl ONLY IN BOX A, I,C"&D
<br /> I. C1reck-only one item in'1TYPE Csi SYS'1J'%1, ,:NK ;tr U'ERIAL, Iti FERIOR LINING and CORROSION PR0''ECFION.
<br /> 2, l"0'I'Ylrii",print it,,the ;space provided,
<br /> IV. PIPING wioitsdivirION
<br /> L Circle A i1 alroo c grourt 1,dr se U if underground,and circle both if applicable.
<br /> 2. 1° 1 N O N'- if C111IE r1 pont to space provided,
<br /> I t.aaiica# the LFAK IrF':11 r"I`10`i sysrcrr(s)used to comply with the tz onit€rring require e nt for the piping.
<br /> V. 'I€NK 11fAK II I`I?C I"IC 1
<br /> 1.. IY,di-ate the >,kA e( C17,11,"('110N :ystern(s)used to comply with the monitoring requirements for the tank.
<br /> VI. IllstrC?WA r 1.ON O Wt YAN" lW I'FI.<RM 1sE 1`I,p' C 1pA SED Its PLACE
<br /> E
<br /> I. F,511MA-FED A-FE 13_Cl`l,'LASk USF?,I1 - NI'I/YE-AR(January, 988 or 01/88),
<br /> 2. F.,;f'lafra.'I'E')OUAN'll'FY of 11;1Z-'t1i13('US SI BS'I`r1NCF.remaining in the tank (in Gallons).
<br /> :g. xVAS'l,F,-eK FILLI-J) W1111 lNFz.p'I'Mx'1'FRIAI,:p C:hcck"Yes' or`NC)'
<br /> APPI;IC 1` UKI"SIC/ AND I)XIIH411111 143RM AS I I31{:U'lgi'I.
<br /> INSI t ICL°ON IraOWI`1IIS I� IC L ACrkti CI
<br /> 'Fhc, state. underground st,r°qgc tank idrratsfic•at"son, number is composed of the two digit county number, the three digit jurisdiction
<br /> narntbcr,01c,sax I};;°. ..__._.k ,umber aad the six digit tank,number, I'Crc county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling ahc State Board (p1rr)739a2321. Che facility number inust ire the same as shown in form "A", 1° e
<br /> tasknumber ana v be as;,a„aw by the local agency, however,this numbermust be numerical and cannot contain an alphabet. If
<br /> the kcal aager ev prefesrs¢ire State Board to aoign the tank number,pleaase leave it blank,
<br /> II°1S' IE R,SPO SI II.I t Y OF TILE LOCAL FACLL, 'L't1 VERIFY THE
<br /> ACCURAC'Y 017 11IE IIWIIaORMA1'0N, '17112 I,0(atgt. OHN( 'IS RESPONSIBLE FOR 11117,t°Ot PIX7,17IO € F 1,71,.,
<br /> `IX-)CAL,AGENCY USE ONLY' ? F ` OIAND FOR K)RWARDING ON MR 'A'AND ASSOC-INIED
<br /> 1k3RNlX31(s)"1`/1'11114,I=CII LOWIlWG ADDRE&S.
<br /> 91'Xp1a Fa CAT F" II
<br /> irwji, wxntR Rusoukats comrIt(F, L21)
<br /> C:/£1 S. .K.C? .5.
<br /> I".(I. IX)X 527
<br /> F'AICa 1s(C3.'NF,C-&90723
<br />
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