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S-IXU(N-IONS FOR COMPLIRING FORM-13-
<br /> GENERAL IMITIRM11ONS-
<br /> 1, o�h er` 1�iI1C11€ A"1'S€� € tsiaeh tank forall .. Vit? 1�I? '€�Tl €�t?i 1C3 "AI and/or any.
<br /> completed
<br /> This form should be c.ompime°d by either the PERmul'APPLICANr or Vie 1,0(7d,AGENCY1,YNDERGROUNDTANK-
<br /> INSPBt,'FOS
<br /> pbs t *fe,ow print clearlyall ra lu steel info-mion..
<br /> n,int writing,a¢ tetar,, >';yO art
<br /> s
<br /> TOP OF POIEVI;* A ` ONLY€NE 1`1 : '
<br /> 1, Stark ;aaa (X)in-the box next to the hent that best describes the reason the form is being comfnetcct.;
<br /> 2 Indseaate the DBA or Facility nanae where the tank is installed.
<br /> 1, 7ANK DE-SC "11CI -COMPI.°r11f All,_rIU1 -IF UNKNOWN m 130 SPIX31cy
<br /> A, Indicate vers tank-fl) If there is a tank number That is used by the owner to identify the tank(ex,AD70789).
<br /> f,, Indicate the name of the compa.,y that manufactured the tank(ex.AC ME`T'ANK S11"O.).
<br /> C. Indicate the year thcc, tank-was installcd (ex.I9 #.
<br /> 1), Ind crate the tank capacity in ggalt«ns(ex,25,(YN or 10,00etc.).
<br /> 11. TANK COMITNI'S
<br /> A, 1,1f N1101011 VETIR 1,I FUELcheck box I and complete items B dr €,
<br /> 2.If riot MOTOR VEHICLE 1°f L,clteck the appropriate box in section'A and complete items B & 11
<br /> . Check the appropriate box.
<br /> Cl, ' Check the type of OTt7 3:`CJEL(if box I is checked in A).
<br /> I), Print the chemical name of the bazardoussubstance stored in the tank and the C°.A.S. .(Chernical Abstract.service
<br /> nunmer),if box 1 is N(YT checked in A, '..
<br /> 111. TANK C"€7 SIRU(1 -MARK ONE rl'EM ONLY IN I :1X 1,B,C:
<br /> 1, t he k only one item in'I ''IFl ts<°§ 1 tj, I<.1 a :a MATERIAL,k"I'I:I1fIA1.I ti I :;IZ1€3If I.;1 '1 Ci andCtC3I2i2(3 1CI v I'I C I'I C`I[ON,
<br /> 2. If t 111,7 ,pont in the sp<aa'e provi srl.
<br /> 1, Circle A if above; -round;circle 1.J if underground;and circle both if applicable.
<br /> 2. If t'Nf:.`IOWN,circle; or if(I'1"1 FIR,print in apace provided.
<br /> 3. Indicate the LEAK T>1,11"C'11CI'sl sysacm(s) used to comply with the monitoring requirement for the piping.
<br /> TANK LEAK I2 4I`II€'nON
<br /> 1, Indicam the LEAK DEFFIC -ION systent(as) used to comply with the monitoring requirements for the tank,
<br /> V1, INFORMAJ70N ON TANK PERMANEN11M(MOSED IN PLACE
<br /> ;� JUl 'T USFI w MO 'I1Ir ^ t (January, 198tiJ .)1. d°` CtDl . sJa
<br /> 2, *iI`l; ATEl ' 1 C;fITANR[°I"Y of HAZARDOUS SUBS'I'ANC F' remaining,in the tank(in Gallons).
<br /> 1, 'WASTANK `fl-LED WITH INERT MA'11:'slts�I,°7 Check `Yc:s'or'NO',
<br /> APPI.IC'Amr MUSF SIGN AND DNIT's'I 1B IX)RM AS I I'I(W1113,
<br /> I LfX7I`1€fkd FOR111F 1..€CAL A NC11a
<br /> Ina° state underground storage tank ,ci-ntil ,,atir:sa number is composed of the two digit county number,the three digit jurisdiction
<br /> number. the sax digit facila,a>number and the ix digit tank nurtat)en `f"he county and,jurisdiction numt)er,,are predetermined and
<br /> cvTt «:a)btaincd ley .«l. tf the State Board (916)7,39-2421, 'The:,facility number must he the.saame as shown in form'A'. '17he
<br /> tan,-, .£aa r,r,ca may tar assigned by the local sagcncy; hovmver, this number must be numerical and cannot contain.an alphabet. if
<br /> the l ,«1 afestt'y.prelers the Stns e board! ..�ign, the hank tmrnb r,please leave it blank.
<br /> IT IS'1"111?RESPONS11I11 i'Y€F`1"111-1,I yC Al<A is I C .I IIAIt l fs'1 C °Ili f ICAC IC,I " C� ? I °I1 ?
<br /> ACCURACY U . CY C1F 111E IN110I 1'1ON, '111 11,LOCAL AGF.N(N. IS R0SPONSIBIJ.1 FORT11B C OMIT ,I I'10]d OF 1711:
<br /> *1X)CAL AGENCY: USE€N *INFORMIVOON BOXANIS FOR rC11C A DING ONE FO 'A*AND ASS&I010
<br /> 1'`€f'lf 'B'(s)TO'1"1111 POIJ€I INN ADDRE!S.
<br /> C70ri.1 1 1.
<br /> 13A'ItA PROCESSING ESSI:''G(T'N"I'1'1
<br /> .C1"ROX til
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