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<br /> One FORM '13'shall be completed for each tank for all N,,'W PLWA4-S,PF"Em H'C1HANW1H`-
<br /> other'TANK INFORMA7110N C-71AINGE
<br /> 2, This form,,,�,,ould be completed by 6ilter the PERMMAPPLTCAT�7 LO(.:AL1,,N
<br /> AG (7Y
<br /> INSPEUP"ill-
<br /> 3. Plcaso tvr r rint clearlyall requested information,
<br /> 1, Use a harp ,+oint wrilr instrument, You are making 3 copies.
<br /> I Rh 'MARK ONLY ONM TIEM
<br /> 1. Mark an (X! in the box next to the item that best describes the reason the farm is being completedl,
<br /> 2. Indicatid tile DDA or Facility name where the tank is installed,
<br /> 'L I'ANK D1,-X,RU1I70N`-COMP1.11111 A.U.r1IMS-IF UNKNOWN-SC1 SPFX,'I.I?Y
<br /> A. Indicate owncrs tank fD # -If there is a tank number that is used by the owner to identify the tank (ex. A1370789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACMFi'GANKivlFG.).
<br /> C. Indicate the year the tank was installed (ex. 1.987).
<br /> 1). Indicate the tank capacity in gallons (ex.15,W0 or 10,(M etc.).
<br /> 11. '17ANY
<br /> A. 1, if MO' 1'R VE111CLE' FULL,check box I and complete items B & C.
<br /> 2. If not VEHICLE FUJEL,check the appropriate box in section A and complete iterns B k 1),
<br /> B. Check thr .appropriate box.
<br /> C. Check the iype of MmOR VEIIlCLF FUEL(if box I is checked in A).
<br /> 1). Print the ,r trnical name of the hazardous substance stored in the tank and the C.A.S4. (Chemical Abstract IY'et'vicc.
<br /> number), if box I is N01'checked in A.
<br /> 111. 'TANK CONSTYRUMON-MARK ONE 1`17M ONLY IN BOX A, B,C&1)
<br /> ''hcck or,'. one item in'I'YPE 0F`SYS'l'FA4,'1ANK INI l"cUOR LINING and CORROSION
<br /> 2. If 0,111EP,print in the space provided,
<br /> TV. PIPINCs INFORIMP-,YlON
<br /> L Circle A 4 abcove ground; circle U if underground: and circle both if applicable,
<br /> 2. 1fUNK\,`%VN, circic5 print in space provided.
<br /> 3. Indicate rrr, 11-�'Alo,Dl-1'lF,C'!"l0N"Y'stcra(s)used to Comply Witt) the rt onitaring requirernew ior the pirinq
<br /> V. 'I'AN K LHAK DFITil!"
<br /> 1, Ind iaic ',., 1,13v' K PET FUTION systern(s) used to comply with the monitoring requirements for Clic tank.
<br /> VL INFORMN11ON 01:q'IANK fl-liiL,ZV,,6,,r MY CLOSTI)IN PIACM
<br /> 1. I-ISFIMA TV111 [Will" 1AS`l'U7SP'1D- (January, 1988 or 01/98
<br /> 2. ES`111%4A`.FD QUANYH I Y of HAZARDOUS SUBS'IANC"F remaining in the tank- (in Onallons).
<br /> 3. WASIANX FILLED W1111 INE"ju MAIERIAL? Cbcck'Ycs'or'NO'.
<br /> v,7', SIGN AND DAIV: I 'FORM AS INDICNII-11).
<br /> LOCAL AGENUES
<br /> 'I'lic state undc-'round storage tank identification number is composed of the two digit county nwilher, the ifirce dipt il-iur,
<br /> number, the kligit facility number and the six digit tank number. The county and jurisdiction numbers ire
<br /> can be obtainc.,a by calling the State Board (916)739-2421. 'I'lle facility number mu,,,o be the same as shown in fonn "A". 'IU
<br /> tank number may be assigned by the local agency; however, this number must be.numerical and cannot contain an
<br /> the local agency prefer,, the State Board to assign the tank- number, please leave it blank.
<br /> 0
<br /> r.11SUIE RUNPONSIBILMY OF'9111i? 2 WW,AGUM.-Y '11INFINSPEC'US111E FACRTI'Y'110 VERIFY17JU
<br /> AC'CTJRAC'Y OP IIIE INIAC RP0 <K:AW,M3EN(TY IS PESPONSIBLU FOR ITIECOMPUMON
<br /> 9,O(IAL AGI-;1,(�USENIN' .R ANS ) O
<br /> CIA'YED
<br /> FORM'W(s), �O'11114,FULID)h
<br /> Of:CAUFORNIA
<br /> 9FAIT!W)VYER RES',0URCFN CXWpROL BOARD
<br /> C/o&Wn'-RP.S.
<br /> DATIA PROCIWUNG Cl %`
<br /> P,0. BOA 527
<br /> PARAMOUM-,(.!A tAT123
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