|
IN1,V17RUCHONS FOR C.OMPL a G I -FIS
<br />OFNERAL I ,x"F UCI1CIIISa
<br />1. One FORM'13' shall be completed for each tank for allNPW E N, ,I2mrr CIIANGF? ,REMO AIS and/or any
<br />other TANK INK)RMA7110N C.'[[IAI CIE
<br />2. "Ibis form should be completed t y either the I�I"'I� I° Al P11C.A i`I` or the I.C1 " L AGEN U I�I2CiiCC3t.) 1 "I'A d
<br />I ,SP `OR
<br />i. Please type or print cleanly all requested information.
<br />4 Use a hard point r -ruing instmmenl, you are making 3 copies.
<br />I I° OF ZCI : 'MARK ONLY Gigli? I'I'1:?t '
<br />1. Mark alt (X) in the box next to the iter, tht best describes the reason the form is being completed.
<br />2. Indicate the DBA or Facility stance where the tank is installed.
<br />1. 1 E CRivri.Cy - COMMC? ALL I' UMS -- r N � Z L ITS
<br />� is
<br />A. Indieate.bweers tame lit # - if there is a. tank number that is used by the owner to identify the tank (ex. AE370789).
<br />D. indicate: the narne of ine company chat manufactured the Sank (ex. ACMES "TANK MFGL ).
<br />C. indicate the year the tank was installed (cx, 1987).
<br />Ii. Indicate the tank capacity to gallons (ex, 25 fiw or 10,000 etc.).
<br />H. TANK CC}. 1' 'I° i
<br />A. L If'v (yFclic VEHICLE i lai`l,, check box I and complete items B & C.
<br />2. If not MOTOR VEHICLE check the appropriate box in section A and complete, items 13 h1 D.
<br />3:, Check the: appropriate box,
<br />C. Check the type of 1vMJ`i'O VEHICLE' E' IV1, (if -box 1 is checked in A).
<br />D,'resat the chemical name of the hazardous substance stored its the task and the C ,A.S.#. (Chemical .Abstract Service
<br />nut )er), if box 1 is NOT checked in A.
<br />III. TANK '0N9I"IZ C 1 ICS - MARK ONE 1`11-,M ONLY IN BOX A, B, C & 3
<br />1., Check only one hent in TYPE UL" SYSTB3WFANK NI TRIAL, INTERIOR ERIOR LINING and CORROSION T'ROTEUIIONN
<br />If fITTf%iZ, print in the space provided,
<br />IV. PIPING III ORMA`ITI3isl
<br />1. Circle A. if abovee ground; circle U if underground, and circle both if applicable.
<br />2. if UNK" OWN, circle; or rt € Tlli iZ, print in space provided.
<br />3. Indicate the LIHAK Df'I F(-1'10 system(s) used to comply auitb the monitoring requirement for the pipin&
<br />V. TANK 11!AK DVITC17ION
<br />1. Indicate the LEAK DFI'E(`J1C1>N s}�tcsn(s) used to comply with the monitoring requirements for the tank.
<br />VI. INFORMA71ON ONTANK PERNA N11,` CLOSED IN PLACE
<br />1 ESTIMATED DATE 1.<AS`I` USED w l ON, `TTI/YFHAFz (January, 1988 or 01/88).
<br />2. TELa[A`FI'D CIL ANTi"1-' of IIA7A,RDOUS SUBSTANCE remaining in the tank (in C3ations)�
<br />3.- AS'DNNK FILLED wri, i INFRT MATE IAL? Check "yes',or'NO',
<br />AI'I'I1 F -F SIGN AND DX1`E'111R FC) RM AS INDICNI ED,
<br />INS IJ("[10N FOR111II, IDCAL S
<br />'Tire state underground storage tank k1cnd£icat'son number is composed' of the two digit county numbert1te�-Ihra e digit jurisdiction
<br />number, the six digit facility number and the, six digit tank number. The county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (916)739-2421, The facility number must be tate same as shown in form °'A'. The
<br />tank number nine be assigned by the loyal agency-; however, this number must be numerical and cannot contain an alphabet. if
<br />the local agency prefers the State Board to assign the tank number, please leave it blank.
<br />YF IS °ITHl RESPONSH3111IN Cllr ILt, LOCAL A , C 1' iNt' INSPINTIN 11113 F CII T7° "IT) VERIFY 111
<br />ACCURACY OF 17II I FO A°110N. '111E LOC AI. AGENCY IS RESPONSIBLE IAC} 1111, COMP[ F .O OF "[`Ilii
<br />'I,3C:Al, AGENCY USI? C�II�t `Y'� IN:1 OMNI -ION PDX Atd11 FOR FORWARDING ONE FORM 'A' Alen) AZSSOC.lIXII'?D
<br />I`A T[: OF CALIFORNIA
<br />C/O S.ird. nps.
<br />WrA PROCESSING G C EN17E
<br />P.OBOX 527
<br />PARAMOUNF, CA 90723
<br />t,
<br />
|