Laserfiche WebLink
STATE OF CALIFORNPI WATER RESOURCES CONTROL BOARD <br /> E <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT <br /> CATION INFORMATION <br /> INSTRUCTIONS FOR COM PLETING THIS FORM <br /> 4tpq MRb°9^ <br /> GEkERAL INSTRUCTIONS: <br /> 1. One FORM °°B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, <br /> REMOVALS, and/or any other TANK INFORMATION I <br /> 2. This farm should be completed by either the PERMIT APPLICANT,or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. <br /> 3. Please type,or prinLclearly_.all requested information. <br /> 4." Use a hard point writing instrument,you are making 3 copies. <br /> TOP OFFORM:" LY ONEITEM" <br /> 1. Mark an(X)'In the box next to the item that best describes the reasgn the form is being completed. x <br /> 2. Indicate the Facility/Site name where the tank is installed. <br /> 3. Is this tank a farm tank?Gheck'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#- 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. 1937) <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 /> 111.TANK CONSTRUCTIONE ITEM ONLY IN A,8,, <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> . 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 primry.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 /> I. INFORMATION TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED -MONTH/YEAR(January, 1958 or 01/88) <br /> 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> 3, WA8-TANK FILLED WITH INERT MATERIAL? Check'YES'or' O', <br /> Applicant must sign ate form as Indicated. <br /> IT IS THE RESPONSIBLITY OF THE LOCAL AGENCY THAT INSPECTS THE'FACILITY/SITE TO VERIFYT 'E ACCURACY OF THE <br /> INFORMATION.T LOCAL AGENCY IS RESPONSIBLEFOR THE COMPLETIONF T 'LOCAL AGENCY USE ONLY"INFORMATIONX <br /> AND FOR FORWARDING F "A"AND ASSOCIATEDF "( )TO THE FOLLOWING ADDRE o <br /> STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOAR® <br /> C/O S.W.E.E.P.S. <br /> DATA 1CENTER <br /> 527 <br /> PARAMOUNT,CA 90723 <br /> �•Y5.8H <br />