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lN9iRtJf t[()fqS FOR G`OIP1..Ii;I yrs 3�,rR-,cW*at"
<br /> a. t.fn.. FORM 13 ;hall bc,comr,Ioed for each tarsk for all NEWERMI TIN, '°; M1'1'CIIANG e, RF, OVAUS and I €"any y
<br /> rotl.(.t 'Ili INFURlNA0'IC:IN C,IIA C15,
<br /> ',phis form should be compcom,
<br /> plc,eci cithe,r the PERM1717AT*PU`" Tor the LOCAL AGUNCY UNDUIR ROUN �
<br /> I "IPUS,7'I0R.
<br /> Please tl c of 1print cleadv alt requcsted informarton.
<br /> C se a ;..,rd pooh �rrt'' zits€rtt ttw,�w�� are making 3 copi� °
<br /> 'IPP OF FORM,-WARK ONLY ONE I-I-EMW
<br /> 1. Mark<. ( �in the box next to the item that nest describes the reason the form is being completed.
<br /> 1 lndi at;the DBA or FacPity nrnte wbcru,the tank is irrstallcd.
<br /> f
<br /> I. °rAN 1.I c (RI1"11(tN '('OMP1..1f"17,i Am fivist -IF UNKNOWN-SX)S , 'IIS
<br /> A. Indicate €evners tank 11) #-If there is a tank number thlt is used by the owner to identify the tan (ex.A.1170789),
<br /> fs, indica- 0te name of+hc compasay that manufactured tured the tank(ex,AC MI:i I`ANK MFG.).
<br /> , Indicate the year the tank was rrstalic I (= 1987).
<br /> D. Indicate the tank capacity in gallons(cle 25,409 or 10,000 etc.) ..
<br /> Il. ' AN .CONTIIsN"I;S
<br /> A. 1_ If ed-0,`I`O VI-1110 LE' FUEL,,check box 1 and complete items B&C.
<br /> 2. If not MC1FOR VFI 11101 1 U13.I„cheek the appropriate box in section A and complete items I1& D.
<br /> Cl, Check tvpc of M 't s OR s a HI 7.I e t a 1, (ii'box .i is checked in A).
<br /> Print th-, ""hem ca, name,of tt.c ha,,li,,d zs,ul,sta Yae stored in the tank,and the C;,A.S,#.(Chemical Abstract Service
<br /> nc°trb .�), if box 1 ,s ch er d in A,
<br /> III, IANK C ONSI"lC;t°:110 -MARK ONE I"I I on()NLY IN I3OXA,II,C&D
<br /> 1, (`heck only one item in"I"I PE-11 Op`S'Y S"pEM,'1AN M U 1"sFltAL,IN`I'1iR1OR,11NINCI and CORROSION I'i8.C7"rIC't'ON,
<br /> 2, If OUTER,,print in the space provided,
<br /> I"Vr PIPING INFORMNrION
<br /> L Circle A if above groundcircle ki if zar c ergr°Lund;and circle both if applicable.
<br /> 2. If UNKNOWN,circle; or if 011MR, print in space provided,
<br /> ;I. Indicate the LFAS DEI I=.C"I ION:systean(s)used to comply*with the monitoring requirement for tire piping,.
<br /> V. 'FANK LEAK ISI ,71-1IO
<br /> L Indicate the LEAK I11,LI?C`1'IO sys'tem(s)used to comply with the monitoring;requirements for the tank,
<br /> VI. Ic"FOR A"101 f-YWI'ANK T$ER II IIXX.YSED IN PLACE
<br /> 1, S1I C'v?'pIl IAI LAS C"SFi.I2 CSI I1I,V A (January, 1988 or 01/88).
<br /> 2. _lSi I' A-['17,D QUAN'S'I"I of Ikdf7=SI2DOU �i I3S"I' RC:If rent ai ainff n the tank(an Gallons).
<br /> 8. YVAS a cNILI F'D WI`E INT,"I AIA'Il'RIAI,a (;heck'Yes'or'NO
<br /> AAPPL1CAI ° UR SIGN AND D/V11VIII i JURM AS DIt a
<br /> IMU'RIX7110N FORITIE LOCW,AC11f: G"IT1,S
<br /> `I'he state underground st mg;e tank identification hurnber is composed of the levo digit county number, the three digit jurisdiction
<br /> number, the ix digit facility nurnber and the eie digit tank number. `rhe county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling-the Slate Boal-d (916)739-2421. 't'hc facility number must be the same as shown in form "A". 11re
<br /> tank nurturer gray be assionc d by the local as ncy, however, this number must be numerical and cannot contain an alphabet. If
<br /> tire local ageacy prefers the State Board to acdim the tank number, please leave it blank.
<br /> I1'IS°ll 1,RUSPONSIBI YI`V OP I`(II-LOCAL twif C:C TI A['I I' "I `Ifl@:? IA(.1.1IX1' `1'0 VER I" 17111
<br /> ACCURACY C11r'111E INIaf:3I11 A'I`f'N, 'I11E 1 rt)CAL AGENCY IS ti::SPO S BLE IrIIIt'IIIc:+(XYMPIE11ON OF"I IT:?
<br /> "i,CI(' r AGfI C USI;ONLY'ICdI'rC' RWY ION IOC ANT) IT)R 1UR A )INN ONE W)RM W AND A%S0t, "I1,D
<br /> IKIRM"Fi(rr)`TY➢111E 1rOL I: WI iGa A }1 tRINS,
<br /> S IWIE .A`DiR 1IIi>S(I1 RCE-S C`,CII "1 OL BOARD
<br /> (*/0 s.wx,-1fP.S.
<br /> PA MOUNT',CA W723 '
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