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FOR
<br /> GUNE'.RAL JN.%'FRUC'I1(IN&-
<br /> L One FORM '13'shah be completed for each tank for al; NEW PERUNS J1ERM1-1'(3LANGNS, RE-1
<br /> other TANK IM�ORWVIION CHANGE
<br /> 1 This form should be cornpletcd by cis her the PERWI'APPUCANT or the LOCAL AGENCY
<br /> INSPEW71"OR. V
<br /> 3, Please r>r print clearly all requested information.
<br /> Use a qint writ rg nistrurneni, yj)14 are mPking 3 c0eies,
<br /> I J I)NE 17
<br /> I Mark an (X) in the box next to the i{ ° that best describes the realton the form is being compIcted,
<br /> 1 Indicate -A' the tank is instv lied.
<br /> 4
<br /> 1. WANK DFLS MIRYWINY -COM1111'1.�:: —°-AS-IV UNKNOWN-
<br /> A. Indicate owner.,tank ID# -If tbcf� is a tank number that is used by the owner to Idthtify the tank(cx:A1370789),
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.).
<br /> C. Indicate the year the tank was installjZd (ex. 1.987).
<br /> 13. Indicate the tank capacity in gallons(er.42,5,000 or I0.000 etc.).
<br /> IT. 'JANK COME[WIN
<br /> A. 1. If MO'?()R VEHICLE FUEL.check box I and complete items B &C.
<br /> 2. If not '=:10`170R VEHICLE DUEL,check the appropriate box in section A and complete items 13 & 1),
<br /> .
<br /> B. Check the appropriate box.
<br /> C. Check the type of mo,roiz.VEHICLE FUEL(if box I is checked in A).
<br /> 1). 'rint the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical Abstract Service
<br /> t
<br /> ,amber),if box I is NOT checked in A,
<br /> as a 'U x 1111 .110N-MARK ONE 1711,;4' `4%,— f oOA,11
<br /> X C&D
<br /> 1. Check only one item 'in'TYPE OFSYSI'EM,'TANK MA'T'ERIAL,INTFFRJOR LINING and CORROSION PROTECI-10-N.
<br /> 2. If O'FIIEV�print in the space provided.
<br /> IV. PIPING INFO RN[JUION
<br /> 1. Circle A if above ground;circle U if underground:and circle both if applicable.
<br /> 2. If UNKNOWN,circle- or if GTHER,print in space provided.
<br /> ,T
<br /> 3. Indicate the LEAK D£ fc],TON system(s) used to comply with the monitoring requirement for the piping.
<br /> V, 1ANF Y TWf,r)ITIY`1[10N
<br /> L' the LEAK D.ETECUON system(s) used to comply with the monitoring requirements for the tank.
<br /> V1 lN -I'ANK PERTWANEWi IN PILAC11
<br /> 1. 1,,S 0,'AA-7 'L,, i),VFE IAS717USED- ?,VfO" JI/YEAR(January, 1988 or 01784
<br /> 2. ESIMAYED Q�UAN`I TFY of ItAZARDOUS SUBSTANCE.remaining in thi tank(in Gallons).
<br /> 3. WAS TANK Ffjq,.D WrIll INERT NMTERIAL?Check'Yes'or'N0'.
<br /> APPLI(ANr MUST SIGN AND DATE UIE InORM AS INDICATED.
<br /> INSTRUCITGN VOR'171 W LOCAL AGENCIES
<br /> ':Che state underground storage tank idcntification number is composed of the two digit county number, the three divit jurisdiction
<br /> number, the six digit facih?v number and the$Jdigit tank-number. The county and jurisdiction numbers are predeternnined and
<br /> can be obtained by callin,,,, '-,e State Board (910)739-2421. The facility number must be the same as shown in form "A". The
<br /> tank number may be as, d by the local agency-, however,this number must be numerical and cannot contain an alphabet If
<br /> =elocal agency prc6�r� State Board to assign the tank number, please leave it blank.
<br /> art p. -N's
<br /> CY S
<br /> 111E UX' IS
<br /> iA)J1,0W1NG ADDRESS.
<br /> V OF'CMIFORNIA
<br /> I WA7ER RES(A j%CJ,!F(X)N`J-R,0L,IY#AJJD,1,,'i
<br /> 3
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