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e <br /> CONTROLSTATE OF CALIFORNIA WATER RESOURCES BOARD <br /> FORMVpUNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> y- <br /> a <br /> INSTRUCTIONS " SFR <br /> GENERAL INSTRUCTIONS, <br /> 1. Ono FORM ,,R„ 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 either the PERMIT APPLICANT,or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4: Use a hard point writing instrument,you are making 3 copies. <br /> T FORM:"MARK LY ONE ITEM" <br /> 1.''Mark an(X) in the box next to the items 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 fans which stores motor vehicle fuel used to <br /> propel farm vehicles. <br /> L.TANK DESCRIPTION—COMPLETE ALL ITS -IF'UNKNOWN-SO SPECIFY <br /> . Indicate owners tank ID##- It there is a tank number that is used by the owner to identify tate 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.1987) <br /> D, Indicate the tank capacity in gallons.(ex.25,000 or 10,000,etc.) <br /> it TANK CONTENTS <br /> A. 1. if MOTOR VEHICLE FUEL,check box;1 and complete items t3&O. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items R&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 CAS, . (Chemical Abstract Service number),if box 1 is <br /> NOT checked in A. <br /> 111.TANK CONSTRUCTIONT L.Y IN BOX A,6, <br /> I. 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 /> 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.andlor 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 Y CLOSED IN PLACE <br /> 1, ESTIMATED GATE LAST USED- MONTH/YEAR(January,1988 car 01/88). <br /> 2, E STI tATED �UANTI 'Y of SI STA CE remaining in tank.(in Gallons) <br /> 3. WAS PANIC FILLED WITH INERT MATERIAL? Check`YES`or`NO'. <br /> Applicant must sign and to form as Indicated. <br /> IT IS TkE RESPONSIBLITY OF THE LOCAL AGENCY T° INSPECTS THEFACILITY/SITE THE THE <br /> F TI LOCAL AGENCYISFOR THE <br /> TI F'THE"LOCAL AUSE ONLY"INFORMATION <br /> STATEAND FOR FORWARDING ONE FORM OA"AND ASSOCIATED FORM"B"(s)TO THE FOLLOW14G ADDRESS: <br /> LIF <br /> WATER RESOURCES:i CONTROL <br /> —C/O S. e a <br /> DATA PROCESSING T <br /> P.O.BOX S <br /> PARAMOUNT,CA 90723 <br />