Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES L BOARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM <br /> ur. = <br /> INSTRUCTIONSTANK TANK PERMIT APPLICATION INFORMATION <br /> LINSTRUCTIONS: <br /> 1. One FORM „S„ shall be completed for each tank for all NEW PERMITS, PERMIT .CHANGES, <br /> REMOVALS, and/or any other TANK INFORMATION <br /> 2. This form should be completed by dither the PERMIT APPLICANT,or the LOCAL AGENCY UNDERGROUNDTANK INSPECTOR. <br /> 3, please typo or print clearly all requested information. <br /> 4, Use a hard paint 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 gest describes the reason the farm is being completed. <br /> 2. Indicate the Facility/Site name where tate tank is installed. <br /> 3_ Is this tank a farm tank?Check'YES`or`NC'. 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 DESCRIPTIONCOMPLETE ALL IT -IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 13#- It there is a tank number that is used by,the owner to identify the tank,(ex.AI370789) <br /> R. Indicate the name of the company that manufactured the tank.(ex.ACME TANK MFG.) <br /> . 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 S&C. <br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. <br /> . 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 stared in the tank and the C.A.S.It, (Chemical Abstract'Service number),if box 1 is <br /> NOT checked in A. <br /> III.TANK CONSTRUCTION—MARK ONE ITEM ONLY IN BOX A, ,C <br /> 1: Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LIKING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided, <br /> 1 �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.LE T CTISYSTEM <br /> 1. Circle P for PRIMARY,or S for SECONDARY, A primary.and/or secondary leafs 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 /> .INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1._ESTIMATED DATE.LAST USED-MONTH/YEAR(January,1983 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 RESPONSIBLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITYISITE TO VERIFY"T CY OF THE <br /> INFORMATION.TSI LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION <br /> C FOR FORWARDING ONE F ASSOCIATED "B"(s)TO THE FOLLOWING ADDRESS: <br /> STATE F CALIFORNIA <br /> WATER RESOURCES CONTROL <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING CENTER <br /> 627 <br /> PARAMOUNT,CA 90723 <br /> Ask <br />