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IN,a"1' UC HOSIS 17OR COMP Cs -Ir
<br /> GENERAL I S"I`i1I iC"I"1C3 9S.
<br /> 1. One FORM"13"shall be cornpleteed for each tank for all NFW PrRMrtN, PII-RMrr C HA CII+S, RFMO AIS and/or any
<br /> other'1 A INIX)RI&N1101S CHANGE.
<br /> 1 This form should be completed by either the PFIRMTr APPIdC'.ANI°car the LOCAL L AGH CY UNDERGRkAJNDTANK
<br /> IIS'T "I"Cyi2
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Usea bard point waiting instrument,you are making 3 copies.
<br /> TOP OF FORM.'MARK ONLY ON] rFEM"
<br /> 1, Mark an (X)in the box next: to the item that hest describes tlic reason the form is beiatg completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> I. 'Ais1 D&SC;1IIP`I1ON-1COM LITFE .La TII1 11 S- F . (y ' -SCI s'L Sf
<br /> A, Indicate owners tank 11) # - 1f there is a tank number that is used by the owner to identify the tank(ex.AI370799).
<br /> B. Indicate tine names of the company Haat manufactured the tank(ex,ACMETANK MFG.).
<br /> C. Indicate the year the tank wns installed (ex, 1987),
<br /> 1). Indicate the tank capacity in gallons(ex.25,00 or 10,0etc.),
<br /> H. TANK CONITIi I S
<br /> A. 1, If MOTOR V1111CLE pUlEIL,cheek box 1 and complete items I3&C..
<br /> 2.If not MOTOR VEHICLE J UEL,check the appropriate box in section A and complete items B<& D.
<br /> B. Check the appropriate box.
<br /> C;, Check the type of MOTOR V'I'IIIC,LL FUEL (if box 1 is checked to A).
<br /> D. Print the chemical same of the hazardous substance stored in the tank and-the-C.A.S.#.(Chentie�l Abstract Service
<br /> I
<br /> number),if box 1 is NOT checked in A.
<br /> III. 'LANK CO S'L RI X-71'101d-MARK O I:?rpFM ONLY IN BOX A,11,C&II
<br /> 1.. Cheek only one item inTYPE 0 S`yS'I'I?M,TANTK MINI` MIAL, INTERIOR I,Ie ING and CORROSION PROTECTION.
<br /> 2, If OTHER,print in the space provided,
<br /> Iv. pIPI ( INFORMATION
<br /> 1. Circle A if above ground; circle U if underground; and circle both if=applicable.
<br /> 2, If UNKNOWN,cirdic;or if OTHER,print in space provided,
<br /> 3. Indicate the LEAK DUI ," 7I`ON systems)used to comply wsth the monitoring requirement for lite piping=
<br /> V. TANK LEAK D PEC171ON
<br /> 1. Indicate the LEAK DLII'?(71'10N systesn(s) used to comply with the monitoring requiretnents for the tank.
<br /> VT. 1NpORk4A'11ON ON TANKI ERMAN LI KI CLOSED IN PLACE
<br /> L I S`I`IMATED DNI`1: IAST USED .MONTI"II/YEA12 (January, 1988 or 01/8 8),
<br /> 2. ESTIMAI`I D QUANITI-Y of ILAZARDOUS SU SI'ANCE remaining in the tank (in Gallons)
<br /> 3. WAS'1'ANK 11 LLED W 'II INERT MNPERI.RL`a Check'Yes' or'NO%
<br /> APPLICANT MUS'PSIGN AND IIATE"I'1 I?I`C3 . AS ITsDK rYI`iI,
<br /> The state underground storage tank identification number is composed of the taro digit comity number, the three digit jurisdiction
<br /> number, the siz digit facility number and the six digit tank mummer, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling tlae State Board(91.6)739-2421, The facility number roust be the surae as shown in form„A". The
<br /> tank number may be asst;ned by the local agency, however,this number mist 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 /> I"1"1S 11I ;RESPONSFBHXrY OF 111 I.,(1., e GFN(Y"TA'I' dSPEATIS'711 rA0117L "1'C3 VERIFY 1111:1
<br /> AC(—'URA( OF'pIIF'ItNFC) XI10 V. '111E LO(AL AGENCY IS RESPONSIBLE?FOR II<COMPL 110N OF 11113
<br /> *L OCAL AGI=.TICS USE ONLY'INFORMATIONAND FOR}k)R AR ASCI ONE FOR *A„ .. d tX11,C2
<br /> I; R °Li"(s)TCI'11111 i1OLLOWING )I ES.S.
<br /> S A'II OF CAIIFORNIA
<br /> 1 A 1 A£1 %lR ROSOURCMS COMI'Rol, ARIA
<br /> CS. i.1-7ps-
<br /> I]ATA PROC ..IN NI'E
<br /> PddC KOX 527
<br /> P (yUNI°,CA 90M
<br />
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