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UC 11ONS FOR CO F..ING FORM
<br /> GENERAL 1"RU O
<br /> 1. One FORM "13"shall be completed for each tank for all NEW PERAUM <RIwffP CIV%NGES, REMOVALSand/or any
<br /> other TANK INFORMATION CIIANGIL
<br /> 2. This form should be completed by either the PERNIff APP11CANT or the LOCAL AGENCY ERGRO
<br /> 1 Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3�eptes,.,,
<br /> ""EYP OF31 ONLY ONF3 rilm
<br /> 1. MArk,.an°( ).in,,Ibe,,bok.,fiext to the item that best describes the reason the form is being completed.
<br /> 2., Indicate theDBA or Facility name where the tank is installed,
<br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex. 870789):
<br /> II, Indicate the name of the craze party that manufactured the tank (ex,ACME TA FG.). ~.
<br /> C Indicate the year the tank`was installed(ex. 29$7). . ...
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).
<br /> w lE d [ a
<br /> `• A. ' I If MC7'I`OR VEHICLE FULL,check box 1 arta complete items B&Cr.
<br /> 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D.
<br /> 11, Check the appropriate beax.
<br /> C. Check the t of;I C?I`E}Et�I I1IC'LE3 L(if box 1 is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C A.S. .(Chemical Abstract ~ 'ce
<br /> number),if box 1 is NOT checked in A.
<br /> III. TANK CON9FRUC11ON-MARK ONE 11THMONLY IN BOX A,B,C&Tt
<br /> 1. Check only one iters in TYPE 01$SYSTEM,TANK MA'IERIAI,INTERIOR LINING and CORROSION PROTECTION.
<br /> 2. 1f C2 ER,print in the space provided.
<br /> TV. PIPING INFORMA11ON
<br /> 1. Circle A if aboveground;'circle`U if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided.
<br /> 3. Indicate the LEAK D- 'ION tem(s)used tai comply with the monitoring requirement for the piping,
<br /> V. TANK LPAK D13qM1717ION
<br /> L Indicate the LEAK DETECFION system(s)used to comply with the monitoring requirements for the tank.
<br /> . INFORMATION ON TANK PERMANENTLY CAI IN PLACE
<br /> �r
<br /> 1. EsmmxrED DATE I.AS"T USED- t3A j'YEAR(January, 1988 or 01/88). -'
<br /> " 2. EI;I'IMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(inGallons),
<br /> 9. WAS TANK FILLED LED WrIll INERT RT M)V ,; L?"Check'Yes'or NO'.
<br /> PLEA .'MUSTSIGN AND DATE THE FORM AS INDICKI'ED
<br /> N,VFR T ON FOR TIW,I AGENCIES
<br /> °„°I'he state underground storage tank identification number is composed of the o digit county number,the three digit jurisdiction,,,
<br /> ~". a number,the six"di it facility number and the six digit tank number, Ile 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 m£orns"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 Board to assign the tank number,please leave it blank.
<br />" IT IS 71111 RESPONSIBRIff OF 111E L AG04CY 77 .°T"INSPEMS 111E FACRM
<br /> "
<br /> ACCURACY OFTHE INMRMATION, TTIE IDCAL AGENCY IS ROSPONSIBLE FORTIIE COMPLL41ON OF
<br /> "LOCAL AGENCY J O 11ON BOX AND FSR FORWARDING O `A!AND ASSOCIATM
<br /> "(s)TO MIE 19LLOWINGADDRES.S.
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<br /> STATE€i i
<br /> STATE. A .Rr' URC r. O 1
<br /> C/o swxx-m
<br /> DATA P W Ci aWD3,R
<br /> O.,PA)X 577.
<br /> Oun90-CA 723 ,
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