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tisrizu "nom 1K7 ;C) i.EIING T `. GENERAL INS.. UCI'IC) S: " "s NEW x r r 1 1. . One Iad� 1:1 shall &>�completed:Eat each tank fat°all Pdl� " $ 1:R TF" CII: , I:, C"A"V' Saladjr,r any other TANK IMIORMA110kIA CD 2. This form should be completed by either thePfIRM.1r APP110W or the LOCAL AGENCY UNDERGROUND'I'ANK 3. Please type or print clearly all requested information. 4. Use a hard point Woting instrument,yrsrs are making 3 copies. 13 -"MARK ONLY ONE tM" 1. Mark an(X)in the box next to the'item that best describes the reason the form is being completed. 2. Indicate the DBA lir IQa614 Barrie where the tank is Installed. 1. 'TANK D&SC R ON a I.EM-9 All,HV ,-IFUNKNOArN A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank(ex.AB70759). & Indicate the name of the company that manufactured the tank(ex.AC:MI:E TAN C 14/li°G':.). C. Indicate the year the tank was installed (ex.1987). D. Indicate the tank capacity in gallons (ex.25,00,0 or 10,000 etc.). IL TANK CC) 'IV I z A: 1.If MOTOR VEHICLE"FUEL,check box 1 and complete items 13&C. 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items FB&D IB. Check the appropriate:(sox. C. Check the type of MOTOR VEHIf:I.1 FUEL(if box 1 is checked in A)> I:t. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. .((.'heroical Abstract Service number),if box l is NOT checked In A. III. TANK CC)a UC;IIO -MARK ow rimm 0M.,Y IN BOXA,11,C&I) 1, Check only one item in TYPE OF SYSTF?M,TANK MA'TIERIAL,INTERIOR 3RIOR LITdI G and CORROSION PRO'IEC`I10N. 2. If C)' ER,print in the space provided. . PIPING INFORMYVnON 1. Circle A if alcove ground,circle U if underground; and circle both if applicable. 1 If UNKNOWN,circle; or if GFIIER,print in space provided. 1 Indicate the 1.1:,XK DETIa010N systena(s)used to comply with the monitoring requirement for the piping. V. TANK LMK DEFIX7110N 1. Indicate the I.,FAK D1.1"I::ECT ION systern(s) used to comply with the;monitoring requirements for the tank. I. I*31 )RM IION ONTANK PERMANEN1 ,Y CI S" 0 IN PIA01 1. i 9rIMATI1)I)A'I II'_I,AST; SED-Mf N`I'II/YI`AR(.January, 1988 or 01/88). 2 0511MATE.13 QUAV"I'I"I"Y of HAZARDOUS SL BI-i 't NCE remaining In the tank(in Gallons). -1. WAS TANK FILLED wI'I'11 INERT MATERIAL? (;heck`Yes'or;NO'. AF Plj(;A `r MUSH SIGN AND DATF 7"I11:'FORM Ali INDI&AT111D. 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)739-2421.. The facitity number must be the same as shown in form "A". The tank number may be assigned by the local agency,however, this number must be numerical and cannot:contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. Irl'IS 171E RIS ) ,911311.,1"I"Y OF"ITIE U)C:AL AG]E 11INI"F SP ECI TIIE F?ACILTI'Y TO VFRIF`Y'nIE ACCURACY O III! RMXIION- `I II?LOCAL AI,ACBENC:Y IS R1:E,S NS1111.11 IDR'IIC4 I,EF'IC) 0111 IIo *LOCAL AGI24CY USE ONLY!INIURMNIION BOX AND MR I )R ARDING ONE]FORM"A"AND `I`ED IX) "(s)T()°I IE FOIA..OWING AIT . S. XITE OF CALIFORNIA, ` "I SII NI"I.IC �''C71tC'IN CC3 F'RC),BOARD DATA PRO 1-%rNG CEINMIR _ P.O.BOX.527 (A