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IlsimmucrIoNs YDR COMPLORNG FA-13-
<br /> OENII L>IN ' .I3C.FI NSm
<br /> I. One FOR "13*shall be completed for each tank for all N, ' TT . N,PEIRmn, II. NCTII� RIWOVATIS and/or any
<br /> otherTANK INFORMKITON CHANG11
<br /> 2. This form should be completed by either the PE I PLIC',A.W or the LOCAL AGENCY UNDERGROUM)TANK
<br /> INS1`., 1L
<br /> 3. Please type or print clearly all requested information,
<br /> . Use a hard point writing instrument,you are making 3-copies.
<br /> }I
<br /> OF Int) 'MARK ONLY ONE FI' I "
<br /> L Mark art (X) in the box next to the treat that(rest describes the reason the'formi is being completed.
<br /> 2. Indicate. the 11 3A or Facility name where the tank is installed,
<br /> 1. TANK DUSCRTITON-Commune ALL ITa S- UNKNOWN-SO STI-13F
<br /> m P,
<br /> A. Indicate oc r r 'talk LIl# -If there is a tank number that is used by the owner to idernify"the tank(ex.AB70789),
<br /> B. Indicate the name of the companythat manufactured the tank (cx.ACMF TANS MFG,}.
<br /> C. Indicate the yeas tate sail was installed(es 1987),
<br /> f), Indicate the tank capacity in gallons(eas,25,M)or 10,W)etc.).
<br /> H. TANK CO ITWI`Ii
<br /> 1. If MOTOR VEIIICLE 14UEL,check.box I and complete items`B& C.
<br /> 2.If not SIOTOR y% ;LIICLE IT pL,check the appropriate box in section A and complete items it XzD.
<br /> B. CTaeck the appropriate box_.
<br /> C,. Check the type of ype oname I). Print the chemical�It,il VFTTIC.L FUEL(if box I is checked in A).
<br /> m of the hazardous substance stored in the tank and the C:A.S, .(Chemical Abstract Service
<br /> ntunber),if box I is NOTchecked in A.
<br /> ITT. TANK C'C)NS"ipICI.cl ON-MARK ONE rI1-,M ONLY IN BOX t, II,C" L)
<br /> f. Check only one item in,,TYPE`fO ESYSTEA`IANX Il~ 1L"RIOR LINING and C.<3ItItOSIO I'I2f)`I F(TI'ION.
<br /> 1 If OTHER,print in thespace provided,
<br /> IV. PIPING INItORMATION
<br /> 1, Circle A if above ground; circle U if underground;and circle both if applicable.
<br /> 3. Indicate NO N circle; or if t?T}IIiZ2 print in space provided,
<br /> the I:AK Ct7 T]h',("t'ION system(s) used to comply withthe monitoring requirement for the piping.-
<br /> V. TANKLEAKDRIW11ON
<br /> L Indicate the LEAK I)F ECI'1ON systerm(s) used to comply with the monitoring requirements for the tank.
<br /> INf ) a A'1'ICSN ON TANK PERMANENJIY CLOSED 1N PLACit 1
<br /> L Ki`1IM/Vr D T)A'i'Li LAST USED -MOIN II/YEAR(January, 1988 or 01/88).
<br /> 2. ESTIM ITd.)Q A?TITI'Y of ILxZARDOUS SU.11 lANC~'I; remaining in the tank(in Gallons).
<br /> 3. WASTANK FILLED WI`T H ITkFTZ'C`M.,'I'FIT 'A.I,7 Check'Yes' or'SIC#';
<br /> APPI1( 4I°S1GN ANT) NIT,?'I`TTH FORM AS i C I
<br /> 1N,5I`RU("1Tf3N FO '11113 LOCAL AG C:II<S
<br /> I`he state underground storage tank identification number is composed of the two digit county number, the three 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 the same as shown in form "A'. 'The
<br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers,the State Tac>a`rd to assign the tank number,please leaves it blank.
<br /> T'C'IS ITIR RESPONS113111IN OF TITI?LOCAL G1 (;Y TI A"C'1N sP `1`,%ITIE FAC 11, `ro VERIFY11111
<br /> AC:C U C.'Y OF 1117,INFORMATION. '1711'LOCAL AGENCY IS RESPONSIBLE FOR17111 COMPLI-SlION OF 11113
<br /> 'W(AL A0ENCYUSE'ONLY"INIf'C) . '1'C I°I BOX AND fUR 14C)I( ARDINC3 ONE FORM'A"AND ASSOCINMID
<br /> MRM"I3"(s)"1 C3`TTIL?TsOILOWING,ADDRI S,
<br /> y I I`11'i f OF C I k)RNI
<br /> I
<br /> C;/C)swi .I'.5..
<br /> P.O. BOX 527
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