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D. Print the chemical came of the hazardous substance stored in the tank
<br />number), if box 1 is NO'I'cheeked in A.
<br />III. TANK CONS MUMON - MARK ONE MM ONLY IN DO X A, A C & D
<br />1. Check only one item in TYPE OF SYSIMM,TANK MAffj',IUAL_IN,
<br />1 If 01111311, print in the space provided,
<br />IV. PIPING INFORMNITON
<br />1. Circle A if above ground; circle U if underground; and circle both if a
<br />2. If UNKNOWN, circle; or if 017HER, print in space provided.
<br />3. Indicate the LEAK DITFEMION systern(s) used to comply with tile r
<br />V. TANK LEAK DMIX37ON
<br />1, Indicate the LEAK DEMCHON system(s) used to comply with the r
<br />VI. INFORMKIION ON TANK PERMANENMY (MOSED IN PIACE
<br />I. F-IsMATED D
<br />1 ES,f,'IMA'11-',D 0
<br />3. WAS'I'ANK I'll
<br />APPIICAMr MUI�f SIGN AN
<br />Mq I-Agr USED - MONTH/YEAR (J
<br />'17111 INE�'RT MXFERIAL? Check 'Ye
<br />IN,'cTFP,U(3'IION FORMIE LOCAL ACAERNICIES
<br />The state underground storage tank identification number is composed of
<br />number, the six digit facility number and the six digit tank number. The c
<br />can be obtained by calling the State Board (916)739-2421. The facility nut
<br />tank number may be assigned ray the local agency, however, this number n
<br />the local agency prefers the State Board to assign the tank number, pleast
<br />Yf IS 111LI RESPONSIBUXIT OF '111E LOCAL AGENCY 'I HAT INST
<br />ACC URAC'Y 0F'j'IIE INR)RMJVIION. 1111i LOCAL AGENCY IS R
<br />LO(Yd, AGIWCY USF, ONLY- INFORMNI-ION BOX AND FOR PO
<br />FORM 'Ir(s) 1-0 ITIE 7J.0 DICT DD 7.5.
<br />MMM
<br />, OF CA111k)RNIA
<br />SMIM WNPEA RI&SOURCAIS CONFROL I)OARD
<br />C/o Smjialps.
<br />13NI'A ISR OMSSING CHNIEP.
<br />P.O. BOX 577
<br />PARAMOUNW, CA 9ffM
<br />INS'ERUMONS MR CO.DLII ING FORM *Ir
<br />GENERAL 1.NS1'PJCC-r10N,&
<br />1-
<br />One FORM "13' shall be completed for each tank for all N17W P141
<br />other TANK INFORMAMN (21ANG11
<br />1
<br />'I"his form should be completed by either the PERmrrAP111JCAN
<br />INSPIXIO&
<br />3.
<br />Please type or print clearly all requested information,
<br />4.
<br />Use a hard point writing instrument, you are making 3 copies.
<br />TOP OF FORhC- "MARK ONLY ONE IT
<br />1.
<br />Mark an (X) in the box next to the item that best describes the rev
<br />2.
<br />Indicate the DRA or Facility name where the tank is installed.
<br />L TANK DTISCRIION - COMPI.F111 ALL TMMS - H? UNKNOWN - SO Sf
<br />A.
<br />Indicate cwners tank ID # - If there is a tank number that is used
<br />D.
<br />Indicate the name of the company that manufactured the tank (ex.
<br />C
<br />Indicate the year the lank Aw installed (ex. 1987),
<br />D,
<br />Indicate the tank eapaciiy in gallons (ex, 25,000 or 1.0,(M etc,),
<br />11. TANK ¢C; 'i
<br />A.
<br />1, If MOTOR VEMICLE FUEL, check box I and complete items I
<br />2, If not MOTOR VEHICLE, i-UEL, rlwck the appropriate box in
<br />B,
<br />Check the appropriate box,
<br />C.
<br />Check the "e of MOTOR VERIC11'FUET, (if box I is checked
<br />D. Print the chemical came of the hazardous substance stored in the tank
<br />number), if box 1 is NO'I'cheeked in A.
<br />III. TANK CONS MUMON - MARK ONE MM ONLY IN DO X A, A C & D
<br />1. Check only one item in TYPE OF SYSIMM,TANK MAffj',IUAL_IN,
<br />1 If 01111311, print in the space provided,
<br />IV. PIPING INFORMNITON
<br />1. Circle A if above ground; circle U if underground; and circle both if a
<br />2. If UNKNOWN, circle; or if 017HER, print in space provided.
<br />3. Indicate the LEAK DITFEMION systern(s) used to comply with tile r
<br />V. TANK LEAK DMIX37ON
<br />1, Indicate the LEAK DEMCHON system(s) used to comply with the r
<br />VI. INFORMKIION ON TANK PERMANENMY (MOSED IN PIACE
<br />I. F-IsMATED D
<br />1 ES,f,'IMA'11-',D 0
<br />3. WAS'I'ANK I'll
<br />APPIICAMr MUI�f SIGN AN
<br />Mq I-Agr USED - MONTH/YEAR (J
<br />'17111 INE�'RT MXFERIAL? Check 'Ye
<br />IN,'cTFP,U(3'IION FORMIE LOCAL ACAERNICIES
<br />The state underground storage tank identification number is composed of
<br />number, the six digit facility number and the six digit tank number. The c
<br />can be obtained by calling the State Board (916)739-2421. The facility nut
<br />tank number may be assigned ray the local agency, however, this number n
<br />the local agency prefers the State Board to assign the tank number, pleast
<br />Yf IS 111LI RESPONSIBUXIT OF '111E LOCAL AGENCY 'I HAT INST
<br />ACC URAC'Y 0F'j'IIE INR)RMJVIION. 1111i LOCAL AGENCY IS R
<br />LO(Yd, AGIWCY USF, ONLY- INFORMNI-ION BOX AND FOR PO
<br />FORM 'Ir(s) 1-0 ITIE 7J.0 DICT DD 7.5.
<br />MMM
<br />, OF CA111k)RNIA
<br />SMIM WNPEA RI&SOURCAIS CONFROL I)OARD
<br />C/o Smjialps.
<br />13NI'A ISR OMSSING CHNIEP.
<br />P.O. BOX 577
<br />PARAMOUNW, CA 9ffM
<br />
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