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A
<br /> 1`N,`3oTR1JCl10N,S FOR,COMPUIHNG IXYRM 013'
<br /> I I tJC°1.1ONSa
<br /> 1, One FORM'13"shall be completed for each tank for all NEW Pf.Rmns, x r1' 1IAN(3 , REMOVAUS and/or any
<br /> other TANK IMX)RMX110N :1' OFC
<br /> 2, "I'lus Poral shouid be completed by either the PERMHAPPUCANT or the LOCAL AGENCY UNDERGROUND"TAN
<br /> INSP* 71"f):It '
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies,
<br /> i, Mark an(X)in the box next to the item that best describes the reason the farina is being completed.
<br /> 2� Indicate the 15BA"or cifity name whcothe tank is installed.
<br /> I, T: it -6�MpLurl b..�A;', NKNOWN
<br /> A. Indicate owners tank 11)#-«If there is a task number that is usf,d by the owner to identify the; hank(eat.AB70789).
<br /> B, Indicate the naive of the eoaarpany-that manufactured the tank.(ex.ACME TANK MFG.). l
<br /> C. indicate the year the tank was installed (ex. 19117).,
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.),
<br /> 11. TANK CONFENIS
<br /> A. 1. If 11C3'I'C)R VEHICLE a EL,checkboxl and complete items B&C:.
<br /> 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section F1 and complete items B& 1),
<br /> B. Check the appropriate box.
<br /> C,°. Check the type of MC)'iOR VEHICLE M- :?I,(if box i is checked in A).
<br /> D. Print the chemical name of the hazardous substance stared in the tank and the C A.S. . (Chemical Abstract Service
<br /> number),if box I is NOTchecked in R.
<br /> JIL TANK C0N 1'RU 1 O -MARK ONE na ONLY Ll3 BOX A, 3,Cw&I)
<br /> 2. Check only one iters in'1"YPE OF SYSTEM,'I'd$.NK MA"I°In.i2IAL, INTERIOR LINING and CORROSION PROTECTION.
<br /> 2. If OT711EK print in the space provided:,
<br /> PIPINGINFORMA170N
<br /> 1. Circle A if above ground,circle U if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or if OTF EF,prion in space provided.
<br /> 3. Indicate the I, SiC I)L?TI+> C)iN system(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LFAK DMi 7111
<br /> °"indicate the LEAK DIE-F)WfJON system(s)used to comply with the monitoringrequirements for the tank.
<br /> 1. ESTIMATED DATE L,ASI"USED-MON.1711/YI'.AR(January, 1948
<br /> 2. ES`I'IMA:rl--D,QL1ANFITrY of HAZARDOUS SUBSI7ANC E remaining in"the tank(in Gallons).
<br /> 3, WAS FILLED 1k'17"li INERT MATERIAL?Check'Yes'or'NO',
<br /> APPLICANT I3 SIGN ANT) ) `17111 FORM AS INDICA:IVD.
<br /> 1N,5rRUC11ON FOR TI Ill LOCAL ACS. ' ;II S
<br /> The state underground storage tarok identification number is composed of the two digit county number,the three digit Jurisdiction
<br /> number, the six digit facility number and the fix digit tank number. The county and.jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board(I1.6)739-2421. The facility number must be the sante as stiown in form "A". The
<br /> tank number may be assigned by the local agency, however,this number must be numerical and cannot coeapain aro alphabet, If
<br /> the local agency prefers the State:Board to assign the tank number,please leave it blank.
<br /> 1TIC RPNIN) i C1' Ir'Ilij!LOCAL AGINCYITIATINSPEC71S 111H FAC'II..I 'I:'f)VI4 "I71I3
<br /> OI?`111P T 7I 2I$ 17C} I ,1< tiCiFsPdCY IS RE, N II3 F;Ir£)L 111?C t A I�I,L t IC➢ C)I?TIMI
<br /> X) . AGENCY USE � , T)FOR FORWARDING ONE !) -A-AND ASSSa IT
<br /> FORM'D'(s)3.C)11 13-POL1,0WING ADDRESS.
<br /> q
<br /> 137'XITWAUAIt ik, NQ
<br /> CMS
<br /> ` 'NTROLBO
<br /> C/o smap-ii
<br /> aM _:
<br /> 1
<br /> DXfA PROCZSSINGC 4 'x.. ..
<br /> PARAMOUNT,CA 90M
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