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1N1d I`RJJC"I1ONS, FOR COMP HI'I C"s
<br /> GITNIMAL Ii ,a;JIR JC"110N S.
<br /> L One FORM "13"strall be completed for c ach tank for all i S IC I'e,,PERMT17CHANGES, REMOVAIS and/or any
<br /> other%I`r5,NK INFORMA13ON C ITA 'GF'
<br /> 2. This f€?rn,, should be completed by citr c the L SCU , 1*. .,Y UNDERGROUND altOUND TAN
<br /> IN SP (,[1)R.
<br /> 3, Please type or pint clearly all
<br /> 4. Use:as hard poild writing instrument,you rt,,making 3 cooks.
<br /> 'MP OF FORM.'MARK ONLY ONE 1`ITN"
<br /> 1, Mark an (X)in the box next to the iters, that best describes Maw reason the form is being completed.
<br /> 2. "'Indicate the DBA or Facility nanr Ihe]sank is instGaHcd.
<br /> 1. °LANK L3rNCRIV11O -C'"t.MPLUI"C3 All.1`17EM S..FIr UNKNOWN-SO SF`Ix I
<br /> A. Indicate owners tank ID#-1f there is a trek number thast is used by the ca. er to identify the tank(ex,AI370789),
<br /> T3, indicate the name of the cornpany,tha. .,�.n ufactured the tank(, . AI,'.A MF(-3,).
<br /> C:. Indicate the yearthe tankwas installed o,rx; 1987).
<br /> I3. Indicate the tank capacity gallons(c; :°_alt or I(ivty)(1 etc,;).
<br /> IF TANK CON117MFS
<br /> A, L If N401"OR VEHICLE t ttl:lil,check]scab I and complete items I3 &C,
<br /> .If not MOTOR V EIIICLIt FUEL,I ll„check the apprerpriate box in section A and complete;items F3 h3
<br /> 13. -Check the appropriate box,
<br /> C, 'Check tho type of MOTOR V111IC I 1 FUEL(if box 3 is checked in A).
<br /> 13. Print the chemical massae:of the hazardous substance stored in the tank and the(,,A.S. . (Chemical/Abstiact Service
<br /> number), if box I is"SOT checked in A.
<br /> 111. TANK C ON9.1 UC 11O -MARX.ONE M'IM ONLY IN IBX A,B C;&I)
<br /> 1. Check only one item in'11YPEZ OF`'bY 51'E, ,TANK MSA TERIAL, IN][URIOR LINING and CORROSION PRO I"I.;G"1"If:N"
<br /> 2. If 0`711ER,print in the space provided.
<br /> IV, PIPING INFORMN17101d
<br /> 1. Circle A it above ground; circle II if underground; and circle both if applicable,
<br /> 2. If UNKNOWN,circle, or if 0`111 ER,print in space.provids .
<br /> . Indicatethe LF AK f7i"I`t-'C.l`TON systeraa(s)used to comply swabs the,monitoring requirement for the piping.
<br /> 1, Indicate the I,ItAIC IIF.,1T,(-FJC7N systent(s) use(] to comply with the monitoring requirements for the tank.
<br /> VI. INF ORMIVF1ON ONTANK 1 ERMA All ILLY CLOSE[)IN+PLACE,
<br /> 1. I<STININIE t DA I'[,'LAST Lw SF', -IMON I'It/YF- AR (January, 1998 or 01/88),
<br /> 2 1,4I`1i1t°`1iii)ouix.NnifY of HAZARDOUS is Sl."B Ia'ANCT' remaining in the„ tank(in Gallons),
<br /> 1. WAS TANK I~11.LED WITII IN RI ATFIRIrAL? Check 'Yes'or"NO',
<br /> r PPLIC N17 MUST SIG)N AND DKIll'11111 FORM AS 1 I( IVI),
<br /> INSTRUC;1'FON FrG R"11F.14 LOCAL L AGENC;IILS
<br /> The state aaaSrlCr),round storage tank identification number is composed of the two digit county number, the three digit,jurisdiic;tion
<br /> number,the six digit faciiityr number and the six digit tank number. S"he county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. The facility nurnber.must be the same as shown in fen s "A'% The
<br /> tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the Star¢c Board to assign the tank number,please leave it thank,
<br /> 1'F'IS'1111?RESPONS11311XrY 011711111 LOCAL AG1. CY 1"I1NF°1NSPtgC'1`,S"MIF I?A(ILrFY°'1'0 VERIF 'F71 1
<br /> ACCURACY C)a'111F3 I F C 1100. °ITIR IDCAL AGENC Y LS RESPONSIB11117OR THE C OMP 1.110 C)F°t1 11
<br /> "LOC` A(Af, (Y 1JSFI ONLY"INFORMA110N BOX AND FOR ItORWARDING ONE FARM*A"ANDA S( F1<t
<br /> T 1t "F3"(s)"CX)31113 11101.I. WIW;ADDRENS.
<br /> C/o S. ijulp .
<br /> DATA PROCESSING(11'1111'R
<br /> FS.C)„I=527
<br /> PARA C3L NI',C° 90723
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