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L One I't)RM"13"shall be completed for each tank for all NEW PERmns,PI RM r CHANGES,.0"sly, lMOVALS and c;r any
<br /> other TANK INF() A`I`IC)N CHANGE.
<br /> 2. ':17his farm should be completed by either the PE'RNIrl'APPLICANFor the LOCAL AGPEWCY UNDERGROUNDTANK
<br /> INS':4,C170IL.
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you acre making:3 copies.
<br /> -MIS OF FORM- "MARK N ONE I"I at '
<br /> L Dark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA,or Facility name whore the tank is installed.
<br /> A. Indicate owners tank 11) # -If there is a tank number that is used by the owner to identify the tank (ex.AB70789).
<br /> B. Indicate the name of the:company that manufactured the tank(ex.ACME TANK MF(i.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> I). Indicate the tank capacity in gallons(ex.25,000 or 1,0,000 ctr.):
<br /> & 1. If MOTOR VEHICLE ITTEL,check box 1 and complete neti s 13& C.
<br /> 2.If not N-10TOR VI;IIlCLE,FUEL,check the appropriate box in section A and complete items 13 K, D.
<br /> 13, Check the appropriate boxy
<br /> C. Check the type of MOTOR VE'1110,1.I'UI:'T,(if box I is checked in A).
<br /> T). Print the chemical nanse of the hazardous substance sto:rcd in the tank and the C,A.S. . (Chemical Abstract Service
<br /> number), if box I is NOT checked in A.
<br /> III, 'rANK C;C)N;s"T'ICI.lC'noisr-mmm ow i"I'IT, ONLY IN Ik)X ?1,IT,f: I)
<br /> L Check only one iteral inTYPE OF S`rSli Vii,TAN MAT1.'€2IAL, I?,fERICII2 J I°eTl'+G and CORROSION 1'ROTE,C"I`EC:Ni
<br /> 2. 11'OTHEk, paint in the space provided.
<br /> IV. PIPING INFORMA717ON
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable,
<br /> 1 If UNKNOWN,circle; or of O` lH.,.'-R,;n s1E in spacc provided,
<br /> 1 Indicate,the LEAK Dl,I`i'.C:IICtti systern(s) used to comply with the monitoring acquirement for the,piping.
<br /> V. TANK LIAR I)HITX;I10N
<br /> I. Indicate the LFAK'C)I;I1,C'1"ON systems)used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMAMN ONTANK PEIIMANEMMY CLC.).IM IN PIACI
<br /> 1. IiSTI A"1'I"D I)A'I'I I 1 AST USED- OIN I" I/YI?,R (January, 1988 or 01,/88).
<br /> 2. I:� .CIMIVITI 7 QUANT11"Y of LIAC.AI OL S SUBSTANCE-.' remaining ist-t(ie tang(in Gallons).
<br /> 3. WAS TANK [`Il,i=,l:st8 WEIII TNEXI 'clATI'RIAL? Check °Yes'or'O%
<br /> A1,Pu ° mr t.TS`I'SICTtd AND D/V.17'111 ICM AS IN1)IOVIT ).
<br /> 3NS'I"I UCITON R)IC'ITIF LOCAL AG C'II S
<br /> The state underground storage tank identification number is composed of the two digit county number,the three drat jurisdiction
<br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetennitne.d and
<br /> can be obtained by calling the Stake Board (916)739-2✓12I. The facility number must be the same as shown in for A". The
<br /> tank number may be assigned by the local agency:h,r ,ever, 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 /> I`IS 'I l? Y-NP INSIBII.<IFY OF"IME LOCAL AGIMY'llIATINSPIXTS 111171FACILMY TO VI:;ILTI'1''I° E
<br /> ACCURMTY C F 3.1 1g I:NIX 'ITOM 171E Y-C)CAL ACLE?NOY IS ti-SPONS[11.1 I .VI'IIE COMP1,11,11ON OF 17117
<br /> 'ID(AL AGIINOY USE ONLY"INFORMA`7ON BOX AND FOR I°C3IC 'A DICE G ONE FORM'A'AND AW)C"IMED
<br /> R)' 'B'(s)TCI°PILI;FOLLOWING AI7I RFSS.
<br /> STMIT"017 CALIFORNIA
<br /> 1r.C3.BOX 527
<br /> PARAMOUNT,NT,C°ys fsttl`f21
<br />
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