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u- <br /> ► *s <br /> WATERSTATE OF CALIFORNIA T L BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> }$� <br /> Y - R TANK TANK PERMIT APPLICATION INFORMATION <br /> °Wr <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> �tFGRM <br /> GENERAL 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 <br /> 2. This form should fiecompleted by either the PERMIT APPLICANT,orarse LOCAL AGENCY UNDERGROUND TANK INSPECTOR, <br /> 3. Please type or print clearly all requested information. <br /> 4, Use a hard paint writing instrument,you are making 3 copies. <br /> TOP OF :"MARK ONLY ONE ITEM" <br /> 1. Mark an(X)in the box next to the iteral that best describes the reason the form is being completed. <br /> . 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 faun which stare motor vehicle fuel used to <br /> propel farm vehicles. <br /> 1.TANK DESCRIPTIONCOMPLETE ALL IT -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,A 7078 ) <br /> , Indicate the name of the company that manufactured the tank.(ex.ACBE TANK MFG.) <br /> C. Indicate the year tank was installed.(ex.1957) <br /> D. Indicate the tank capacity in gallons,(ex.25,000 or 14,000,etc.) <br /> It TANK CONTENTS <br /> A. 1, If MOTOR VEHICLE FUEL,check box 1 and complete iters R&C. <br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items S <br /> R,,Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL,(if box 1 is checked in A) <br /> 14. Print the chemical name o€the hazardous substance stored in the tank and the C.A.S. (Chemical Abstract Service number),if box i is <br /> NOT checked in A. , <br /> alta TANK CONSTRUCTION—MARK ONE ITEML IN BOX A,B, <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LININb and CORROSION PROTECTION, <br /> 2. If OTHER,print in the space provided, <br /> IV. I INFORMATION <br /> Circle A if above ground,or L 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 rimary.andlor secondary leak detection system MUST be circled. <br /> 2. 1f 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, ESTII ATEU DATE LAST USED-MONTH/YEAR(January,fi RS or 01/50). <br /> 2, ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> & WAS TANK FILLED WITH INERT MATERIAL? Check'YES'or` Q'. <br /> Applicant must sign and date form as Indicated. <br /> IT IS THE RESPONSIBLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE T E FY THE ACCURACY OF THE <br /> INFORNIATION.THE LOCALAGENCY IS RESPONSIBLE FOR THE COMPLETIONT "LOCAL AGENCYPSE ONLr INFORMATION <br /> AND FOR FORWARDINa ONE F "W AND ASSOCIATEDF "B"(S)TO T FOLLOWING ADDRESS; <br /> STATEF CALIFORNIA <br /> WATERECONTROL <br /> B S.W.E.E.P.S. <br /> DATA PROCESSINGCENTER <br /> P.O.BOX 627 <br /> PARAMOUNT,CA 90723 <br />