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GENERAL INSTRU IC)N
<br /> 1, One I ORN-1 '°13" shall be complexed for each tank for all SII:-PI:?1C 1"1°a NEEM;r CHANGES, RI'MOVAI.S and/Or any
<br /> otherTANK INFORMA1710N MANGE
<br /> 2, This form should be cornpicted by cit'her the 1? AP 1 :AN`1'rsr the LOCAL AGENCY NDFROEZC3 TANK
<br /> INfsl'EC FOR..
<br /> 3. Please type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF COMM:'MARK ONLY Y ONE'FREM'
<br /> 1. Nl ark an in, thc; hos, next ,o flw, best t describes e<.,_on the form is
<br /> 2. Indicate V-, DFIA or Fadhiv name tank is irist;a€cer
<br /> 1. TANK L)ES(MVI'I0N-COMPIHIT ALL ENLt, -IF UNKNOWN _1'111X;'II
<br /> A. Indicate c-xners tank ID # -If there is a sank number that is in,the;owner to identify the tank (ex.A1370789).
<br /> 13. Indicate name:of the company tha rs.=nufactured the tank •.x. TANK MFG.).
<br /> C. Indicate thc year the tank was installer't x. 1.987).
<br /> 1). Indicate Via tank capacity in gallons(cx ',000 or 10,(W etc.).
<br /> Il. TANK CONIVNIN
<br /> A. 1. If MOTOR VI:`sI1ICI_II FUF"L,check box"I and complete iterns 13& C:
<br /> 2. If not M011OR 1II10I F h'C;EL.,check the appropriate box in section A and complete items 11 &D.
<br /> B. ('Reck the appropriate box,
<br /> C_ Check the!y,P e o -A,1 1"OR VEHICLE,FUEL(if box't is checked in A).
<br /> 11 Print the chemical nsanie of the hazardous,substance stored in the tank and the C.A.S4. (C;'hemieal Abstract Semice
<br /> number), if box 1 is'sOT checked in X
<br /> III, TANK CONS RII 710N-MARK C)Nt1 IOiM ONLY IN Im A, 13,Cd&I)
<br /> 1. Check only one uern is TYPE OF ti S'TT ,'I'ANNK NINI'T,,A] I,INMIRIOR LINING and CORROSION I'I2C TE",C'T'It?'ti,
<br /> 2, Lf O'1'I3'3is ,print in the apace c avided,
<br /> IVa PIPING RMX I0
<br /> 1, Circle A if above growid; circle Ulf urt dcrground; and circle both if sppliaable.
<br /> 2. If UNKNOWN,circle; or if OTHER,ER, print in space provided.
<br /> 3. Indicate the LEAK DE-FECT11 N systcm(s) used to comply with the monitoring requirement for the piping
<br /> V. TANK I..T;AIC I71 1'I X7110N
<br /> 1. Indicate the LEAK DE"I.I; T110N sy-stem(s) used to comply with the monitoring:requirements for the tank.
<br /> VL INFORMMION ON TANK ICER ANEIV` Y C,IA SEI)IN PLAC U,
<br /> 1. F-4"IIMATED DATE',LAST USFD-MC)N'riI[Y AII.(January., ].'M8 or 01/88).
<br /> 2. E"911 1A'I'I I) QUA.N I°T IT of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED WITH INii RT r Al ERIAL,'I Check'Yes'or`NC)',
<br /> APP1.,1(;A I.' usr SI(w ANI)I)AT'I3'n w ik)RM AS I )I(W1711).
<br /> INS7FR ICUTON I?OR°nlE LOCAL AGENC,IILS
<br /> J'he state underground storage lank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number, the six digit Caciii(y number and the six digit tank number. The county and jurisdiction nunibers are predetermined and
<br /> can be obtained by caking the State Board (9I6)739-2421. The facility number must be the same as shown in form "A". 1he
<br /> tank number may be assigned by the legal agency; however,this number must be numerical and cannot contain in alphabet. V
<br /> the;local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> rr IS um,Ri.,spoNsiBuiry OF 111ELOCAL OC AI.,A ENC Y 171ATr.INSPI 'S T E I:I:i FAC.'ll '1'C)VERIFY`1111
<br /> AM'URACY OF171E Iii FO A71IC)N. THE LOCAL AGINCY IS aSPON,13UBLE FOR'ITIE COMPLIMON OF TIIE
<br /> OLOC.AL AGIINCY USE ONLY'INFOR A I`ON IX)X ANIS MR FORWARDING ONr:FOR 'A«AND A4,`">(}CJXII'D
<br /> FORM"I3-(s)`TC)"lllli 1701 AMI G Ai"fDR N`.
<br /> '.A°Ii,OF CALI )RNIA
<br /> ate'o:!E,F RPNOURMTS 1C 1rfROI,BOARD
<br /> PO.I3C3 . 12:
<br /> PARAMOUNT,C)C1NT,C°;A f 3
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