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INKIMUCHONS FOR COMPLYSIT.NG J*-Tr
<br /> GENERAL INSiFRF,.FC.°F IIONS,
<br /> 1, One FORM'13"shall be completed ted fear each tank for all NITW NITPERNM.N, I ERM17`C:F. NCIIN, REMO AI S and/or any
<br /> otherTANK INFORMNOON 1 NCs"Ii
<br /> 1 This form should be completed b1'either the I l'. F"I.LCANI'or the LOCAL L< LI NE N LT LCILt T.1N.T'IAN
<br /> INRnI'.CF`C31t
<br /> 3, please type or print clearly all requested information.
<br /> al; 1,sc a hard point writing instrument,you are rra3km9,3 copies.
<br /> TOP OF FORM. 'MARK ONLY oNK altsw
<br /> 1, Mark an(X) in the box next to the item that Fest describes the reason the form is being completed.
<br /> 3. Indicate the DBA or Facility name where the tank is installed,
<br /> I. TANK DEISCRIP1101st--fX)MPLF"rF?ALL HEMS-'IFS"UNKNOWN-SO STT `
<br /> . 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_ACMETANK NK k%FG.).
<br /> C:. Indicate the year the iank was installed (ex. 1987).
<br /> ii. Indicate the tank ._parity in gallons(cx.. 25,000 or M000 etc.).
<br /> TANK 'ON'1"?,!a'
<br /> 1. if\AO`]'ORi II HIC1,i,FUEL,check€ox I attd complete items 13& Cl
<br /> 1 If not MOTOR VEHICLE FUEL,check the appropriate box in section and complete items 13 & IT.
<br /> 11, c1reck the appropriate late bo .
<br /> F.:. Check One type M(YY R VI'111C.I.E I`C F I:,(if box 1 is checked in ),
<br /> D. print rile cl-wrntcat name of the haFardous substance stored in the tank andtheC,,A,S,#. (Chemical abstract Service
<br /> nunr t ), s1 box I s NoT checked in.k.
<br /> 111. TANK CON,5,f1`RUCPF"1O --MARK ONE rpEM O .:'IN BOX IL, I3,C:&F)
<br /> 1. Che:ck tartly one ucm in"I`"r'PE OF t;Y`TF4,"1'ANK;V3 x'4'1"FaIUAL, INFF'RIOR LINING and CORROSION I'ROTFCTION.
<br /> 1 if OTHER,print in the spice provided,
<br /> IV. PIPING INia`fIRMA'L'ON
<br /> 1. Circle A if abs e grcau,ad,circle U if underground; and circle,both if applicable,
<br /> 3 If UN `O'lti c a or if 0411€IC..print in space.provided,
<br /> 3. Indicate the I<F,Ad ,)pea 1.t 1'FON slstar,.aats) used to comply with the monitoring requirement for Site Lsipmg.
<br /> V, 'TANK LIL&K DITITY7110N
<br /> lndicatc file 1.1.> E FC°1°Its N system(s) used o comply with the monhorim,reeiasirstnents for the tank.
<br /> VT. INFl3ICMpa11ON ON TANK Ln1fRMANFr,N°F'A CLOSI TI IN PIACE
<br /> 1. I§I`IST:I dD 1'AT , L.fi ST£`SI -MOIN 11I/Y F,AR(January, 1988 or
<br /> 3. T LI?tTzy ED C1k,Aa~'l,'F I"f of!IAA RI)OUS SUBST' NC T.rcniai ing in the tank (in Gallons)_
<br /> .s. 'WAS TA, 1`1 L;. F' 11-1I INF I<,`I A'11;IFIr1I.,'•Check 'cs'or°N()'.
<br /> PPT IC AN MTJS`F SKIN AND DNIT I`I HE FORM AS INT IC ;F'LT11.
<br /> sis rIILTCTI ON FOR1111s`F1:s I.CFC"a ,AGENCIES
<br /> The state underground storage tank identification number is composed of tIhe two digit county number, the three.digit jurisdiction
<br /> number, the six digit ficility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtr meat by calling tee`:tate Board (916)739-2421, The faacility atuaailler crust be the same as shown in forma A". The
<br /> lank ruynber may be ss:k ed by the focal agnate; hovever, this number must be nufner;cal and cannot contain an alphabet, I
<br /> the, local alrency prs€c,the `prate.Board to,assilm the tank number,please leave it blank,
<br /> T f IS'HILI RESPONSIBBIFY CIF 1111f LOCAL AGENCY'1IA:' NS E(TIN HITT F CwII11 a'"I°CI VERJ11Y'TL°Ftl l
<br /> ACCURACY OFr 111F INFORNIAI'ICTN. 'ITIE LOCAL AGENCY IS RESPONSIBLE FOR'ITS,C1t1 L"IE ON OF"I1IFT
<br /> 11 CF(, L AGENCY USH ONLY"INF°ORMiV11ON BOX AND FOR F )RWARDING ONE ITORM'A4 AND ASSOCIA71ED
<br /> FORM "F3'(s)`10 THE IttOT,I 0 ING z1DDRE. S.
<br /> ,517t;07 OF QUIFORNIA
<br /> [° WNIT,,R RESOURCIIS C CLNIM01 RD
<br /> C/o S. :11-7-p.1a.
<br /> I*.C). MIX 527
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