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INf1T"TLIJcnoms M.RCi 11111 G IK)RM"II" G'UNFRAL INT,. UCII t3 a 1. One FOR "Il"shall be completed for each tank for all NEW PBRMn.',S, PERMrr C:1 GEA REMOVALSand/or any other TANKIMX)RMA11ON CHANGE 2. This form should be completed by either the PERWr APPLI(AW or the LOCAL AGENCY UNDERGROUND TANK SP I'C3I 3. Please type or print clearly all requested information. 4. . Use a hard point 'ting instrument,'you are anaking 3 copies,. . , r )I� OF FOR C NLV C) rI 1 I" I, Mark an(X)in the box next to the item that best describes the reason the form is being completed. 2. . Indicate the DBA or Facility name where the tank is installed. I. TANTS I,ESCbli ON-(Y)MPTHIM ALL THY -H? O «SO SPPXM?Y A. Indicate owners tank:ILS #- If there is a'tank number that is used by the owner to identify the tank(ex.AB70789). I3. Indicate the name of the company that;manufactured the tank(ex.ACME:TAN C MFG.). C. Indicate the year the tank was installed (ex: 1987). I). Indicate the tank capacity in gallons(ex.25,0W or 10,000 etc.). T.I. TANK C ON11r A° A: 1. If MOTOR VEHICLE L DUEL,check box 1 and complete items B& C. 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. B. Check the appropriate box. Cr Check the,type of MOTOR VEHICLE FUEL L(if box I is checked in ). I). Print the chemical name of the hazardous substance stored in the tank and the-C;.A.S. .(Chemical Abstract service number),if box l is NC7°I checked in A. III. Till{.CCI: S Turk) -mARK or4E rrow oNix IN WYX A,I3,C.°&IT 1. Check only one item in TYPE OF S1 .M,'I°ANK MATERIAL,INFERIOR LINING and CORROSION I'ItCST C 110 . 2. If OTHER,print in the space provided, I . PIPING INFORMN170N 1. Circle r0.if above ground;circle U if underground;and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the IaEAK I)E'lIf CSN system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DHI` -.IICI 1. Indicate the I,1�1313.1131CTION systern(s)used to comply with the monitoring requirements for the tank. Vl. INFORM101ON ONTANK PERMANIWILY CLOSED IN PIAC[? [? 1. s;,S11MA'1111)I ATE.'LAST USED-MON'l-It/FEAR(January, 1988 or£11/88). 2. TlMATED C?I-tAN'I`rpY of HAZARDOUS SUB51'ANC.E remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INI::iI2'Z MrVI'I✓F2.IAL? Check 'Yes'or'NO'. JtIkPI,tC?tNI' t3ST'SICK DA`Z`E 111E FORM ti..S INDICA7110, jN,,;rRUC110N FORnrE I AI../#C.Ir1 CIU The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(91.6)73e9-2421. The facility number must be the sante as shown in form"A". The tank number may be assigned by the local agency however, this numf)cr must be:numerical and cannot contain an alphabet. If the local agency prefers the state:hoard to assign the tank number,please leave: it blank. IT is TE:m REspomsmuxiy OF T III LOCAL .CII 11If' F SPIX71S 11113 IrA011PY'T'CI V '°mil:? ACCURAC Y OF 11IT: 1 It A°I1ON. 'ITIE LOCAL AGENCY Is TAT AS .NSIBL E FO '1131:COMPIHITON 017 11113, 'LOCAL AGINCY USE ONLY*INPORMA'nON 11OX AND FOR FORWARDING ONE FORM"A7 AND ,S.° '17ED 'CI 'IP(s)TO111H 114011.)OWING ADDRESS. STNIE OF CALIFORNIA, C/o bs. ap.& DATA I'T2t7t,"1�S.S CI C.`'T?Nnll P.O.BOX 527 PARAMOUMr,C