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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ffFORM ` <br /> Q 9a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION <br /> , tr <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> GENERAL ST 'TI , <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 <br /> 3 This form should be completed by either the PERMIT APPLICANT,or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. <br /> . Please type or print clearly all requested information. <br /> 4, Use a"bard point writing instrument,you are making 3 copies, <br /> TOP OF FORM:" ONLY ONE ITEM" <br /> 1. lark an(X) in the box next to the herr}that best describes the reason the form:is being completed, <br /> 2, Indicate the Facility/Site name where the tank is installed: <br /> & 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 /> I,TANK DESCRIPTIONCOMPLETE ALL ITERIS-IF " -SO SPECIFY <br /> A. Indicate owners tank IU#-It there is a tank number that is used by,the owner to identify the tank,(ex A1370789) <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.1957) <br /> , 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 6&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D , <br /> S, Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL.(if box I is checked in A) <br /> D, print the chemical name of the hazardous substance stared in the tank and the C.A.S.##' (Chemical Abstract Service number),if box 1 is <br /> NOT checked in A. <br /> IIIb TANK CONSTRUCTION�-MARK ONE ITEM ONLY IN BOX A,B,. <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 /> I ;PIPING INFORMATION <br /> 1. Circle A if above ground,or L if underground;circle troth 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 pr'smary.and/or secondary leak detection system MUST be circled. <br /> . 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 ON TANK PE E 'TLY CLOSED IN PLACE <br /> t: ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1 car 01/SS). _ <br /> 2. ESTIMATE QUANTITYof SUBSTANCE remaining in tank.(in Gallons) <br /> 3. WAS TANK FILLED WITH INERT TMATERIAL? Check`YES`or`NC'. <br /> Applicant must sign and date form as Indleate& <br /> IT IS THE RESPONSIBLITY OF THE LOCAL AGENCY"THAT INSPECTS THEFACILITY/SITE TO VERIFY THE ACCURACY OF THE <br /> INFORMATION.THE LOCAL AGENCY IS RESPONSIBLEFOR THE COMPLETION OF THE"LOCAL AGENCY USE LY"I TI <br /> AND FOR FORWARDING E FORM"A"AND ASSOCIATED F " " TO THE FOLLOWING <br /> STATE OF CALIFORNIA <br /> WATERS CONTROL BOARD <br /> C/O S. <br /> PROCESSINGDATA <br /> P.OBOX T <br /> PARAMOUNT,CA 90723 <br />