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STATE OF CALIFORNP WATER RESOURCES CONTROL BOARD
<br /> FORM £ gqUNDERGROUND STORAGE TANK PROGRAM
<br /> �P a
<br /> APPLICATIONTANK TANK PERMIT
<br /> 1
<br /> INSTRUCTIONS FOR COMPLETING THIS FORM
<br /> 4I F(S PBA\P
<br /> GENERAL
<br /> INSTRUCTIONS:
<br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT C ,
<br /> REMOVALS, and/or any other TANK INFORMATION EA
<br /> 2, This form should be completed by either the PERMIT APPLICANT,or the LOCAL ACY UNDERGROUND TANK INSPECTOR.
<br /> 3. Please type ser print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF FORM:"'MARK ONLY ONE ITEM"
<br /> 1. Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<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 /> I.TANK DESCRIPTION—COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY
<br /> A. Indicate owners tank ID#- It 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 /> 11 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 /> III.TANK CONSTRUCTION—MARK ONE ITEM ONLY IN BOX A,8,C,
<br /> 1. Check only one iters 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 DETECTIONSYSTEM
<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 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'Y 'or'NO'. A `
<br /> Applicant must sign and date form as Indicated.
<br /> IT IS THE RESPONSIBLITYOF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION,TLOCAL ACY IS RESPONSIBLETHE COMPLETION OFT" E" C CY USE ONLY"INFORMATION X
<br /> DAND FOR FORWARDING F "W AND ASSOCIATEDP " °"O TCT E FOLLOWING ADDRE eSTATE OF CALIFORNIA '
<br /> WATER RESOURCES CONTROL BOARD
<br /> C/ <E< < ,
<br /> DATA PROCESSINGCENTER
<br /> 527
<br /> PARAMOUNT,CA 90723
<br /> 3 15-96
<br />
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