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UNS'FRUCTJONS POR"- `M- VLF1TNG W)RM 131'
<br /> NNS
<br /> OFNERAL INIURILTCH-C, --
<br /> 1. One FORM '13'shall be completed for each tank for all NEW PERMW�-'S,PERMUCIL A
<br /> other'IANK INFORMA71TON CHANG17-
<br /> 2, This form ti ould be completed by c;ihcr the PURMUAPP11CANT or the LOCAL AGU,NC
<br /> INSPFCI'OR
<br /> 3, Please ly, ,r print clearly all requc,,ted information,
<br /> 4. Use a bav,-,, 1-oint wrif;ng instrument, you are niaking 3 copics,
<br /> 'I'OP OF TK)RM,WARK CNIX ONt TI'-,-M-
<br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 1 Indicate the DBA or}Facility name where the tank is installed.
<br /> I. TANK DE-SCRUY11ON-WMPTITIU AU,T1T??WS-IF UNKNOWN--SO SPFC11rf
<br /> A. Indicate owners tank ID # -If them is a tank number that is used by the owner to identify the tank (ex.AB7Q'--'P911*
<br /> B. Indicate the name of the company that manufactured the tank(=ACME TANK MFG.).
<br /> C. Indicate the,year the tank was installed (ex. 1987).
<br /> 1). Indicate tl,c tank capacity in gallons(ex.2.5,(Y)O or 10,(00 etc).
<br /> II. '17 ANI{ CON11WES
<br /> A. L If MO'- T2 VEHICLE FUEL,check box I and complete items B &- C.
<br /> 2. It'not '-I,OTOR VE'Il.lCI,E FUE.L, check the appropriate box in section A and complete items B & 1),
<br /> 13, Check the -lppropriatc box.
<br /> C. Check the type of MOTOR VEHICLE PUEL(if box I is checked in A).
<br /> 1), Print the name of the hazardous substance stored in the tank and the C.,A.S.#. (Chemicni Abstraci SC3v. icc
<br /> number), i1 box I is NOT checked in A.
<br /> 111. TANK CUNSYRUCITON-MARK ONE riTim ONIN IN 13OX A, B,C&1)
<br /> I. Check oril, one item inTYPE OFSYSTE�NT,TANX MATERIAL, INTERIOR LINING and CORROSION PROFC1"10N,,
<br /> 2: If 0TIIFs'- print in the space provided.
<br /> W, PIPING INK)RMIA"l-ION
<br /> 1. Circle A,f abcwc groundcirc-le U if undergri.-mad- and circle hoth if
<br /> 2, 11 UNXN�VVN, or if OTHERprint in space provided.
<br /> 1 indicate e,a. LT]AK Dj�,')F(T10Nsa=wn M(s)use to cornplvl,cith the monitoring Cor the vinin�.
<br /> V, TANK LEAK DUD ,'-FION
<br /> L Indiewe LEAK DF1'I-.(:FION system(s) used to comply wall ilhe lnorlitorin- rciluiremen-s for itle tarlk.
<br /> VL INFURNMTJON()N TANK PERMANEN'11Y CLOSED IN PLACT
<br /> 1. ES'SMA t'':D DATE, 1ASTUSI.,"D - ',vI0rTl1/YEAR (January, 1988 or 01/88).
<br /> 1 aSHMAO I)QUANTITY of TWARDOUS SUBSIANCI, remaining in the tank(in Gaflous).
<br /> 3. WAS TANK FILLFI) WFHT IN140"MAWRIAL? Check.'Yes'car"NC)'.
<br /> ci
<br /> APPLICANI'MUSTI'SIGN AND DA`117111E Ik)RM,AS INDI(WIVU
<br /> IN,'5I'R(JC'J10N FORTHli LOCAL ACHINC IUN
<br /> I'he state e. roiwid slormye tank identification number is composed of the two digit ci,)unty number. the three dqg'i!
<br /> number, digit facility number and the six digit tank number, 1be county and jurisdidion nunibet^ are prcdc1cin;1led r�w,0
<br /> can be obw;, t,v calfinc,the State Bimrd(916)739-2421. The facility number mustt)e the sante.as shown in form "A". Vhc
<br /> tank numbc- a assigned by the local agency; however, this number must be numerical and cannot coot"un, an aioha=,aa, 1i
<br /> the local avc'l - cfers the State Board to assign the tank number, please leave it blank.
<br /> Ti'IS'1`11E RkSPONSIBILUY OF 111E LOCAL AGENCY'11INVINSPFC-US7111H FACIT.Tf.YTO VERIFY 11W
<br /> ACCURACY')I7`(7113 INFORMA'110M '11111 LOCA1,AGIlNCY YS RI-4SPONSIBI11 FORTFIF COIN11PLE11ON1 OF'ITIU
<br /> "LOCAL ACWNCY USE ONLY'INFORMA11ON 1"X AND FOR FORWARDING ONE'FORM'A'AND ASSOC'IND 111)
<br /> FORM-Fr(s)T011114,FOLLOWING ADDRUSS.
<br /> S717NIT!,OF CAUVORNIA
<br /> SrA7111 WA'YER RUSOURCHS CONTUROL WARD
<br /> C/o Smu,-*�Lps.
<br /> Vf"7A rROCESSING CE11VITR
<br /> PXI).W-3--K 527
<br /> PARAMOUr,rl', (A W77-3
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