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STATE OF CALIFORNIA • WATER RESOURCES CONTROL B RD <br /> FORM W: UNDERGROUND STORAGE TANK PROGR M <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> 0 <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, TANK CLOSURES, TANK <br /> REMOVALS, and/or any other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT,or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. p <br /> N <br /> TOP OF FORM:"MARK ONLY ONE ITEM" W <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. W <br /> 2. Indicate the Facility/Site name where the tank is installed. <br /> 3. Is this tank a farm tank?Check'YES'or'NO'. A farm tank is a tank located on an agricultural farm which stores motor vehicle fuel used to <br /> propel farm vehicles. <br /> 1.TANK DESCRIPTION—COMPLETE ALL ITEMS- IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID ft - 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 MFG.) <br /> C. Indicate the year tank was installed.(ex. 1987) <br /> D. Indicate the tank capacity in gallons. (ex.25,000 or 10,000,etc.) <br /> II TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL. (if box 1 is checked in A) <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number),if box 1 is <br /> NOT checked in A. <br /> Ill.TANK CONSTRUCTION —MARK ONE ITEM ONLY IN BOX A, B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER, print in the space provided. <br /> IV.PIPING INFORMATION <br /> 1. Circle A if above ground,or U if underground; circle both if applicable. <br /> 2. If UNKNOWN, circle or if OTHER, print in space provided. <br /> V. LEAK DETECTION SYSTEM <br /> 1. Circle P for PRIMARY,or S for SECONDARY. A primary and/or secondary leak detection system MUST be circled. <br /> 2. If UNKNOWN, specify or if OTHER, print in space provided. <br /> 3. If there is no SECONDARY LEAK DETECTION SYSTEM, circle NONE. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED - MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check YES' or'NO'. <br /> Applicant must sign and date form as Indicated. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF THE <br /> INFORMATION.THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION BOX <br /> AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS: <br /> STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 90723 <br /> 3-15-88 4 <br />