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STATE OF CALIFORNIA WATER RESOURCES
<br /> CONTROL, y^ ppgs
<br /> FORMV
<br /> ♦ UNDERGROUND STORAGE TANK PROGRAM
<br /> IN$T- �VCT,- IqNS,F0R COMPLETING THIS FORM
<br /> E Ubi rl, "�,0
<br /> TANK TANK'.PERMIT APPLICATION INFORMATION
<br /> GENERAL
<br /> INSTRUCTION&
<br /> 1, One FORM ,:R„ shall be comp,fefe d to r`ea O.t nk for all NEW PERMITS, PERMIT
<br /> REMOVALS, and/or any other TANK INFORMATION
<br /> 2. This form should be completed by eitt4e Che O&MIT APPLICANT,or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 3. Please type or print clearly allctdt.arsfistrrrtio :
<br /> . Use a hard point 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 best describes the reason the form is bung completed,
<br /> 2."Indicate the Facility/Site name where the tank is installed.
<br /> , is this tank a farm tank's Check`YES`or` ', A farm tank is a tank located on an agricultural farm which stores aviator vehicle fuel used to
<br /> propel farm vehicles.
<br /> 1.TANK DESCRIPTIONALL ITEMS-IF UNKNOWN-SO SPECIFY
<br /> A, Indicate owners tank ICS#-It there is a tank number that is used by the owner to identity the tank.(ex.AB707 9)
<br /> R. Indicate the name of the company that manufacture the tank.(ex.ACME TANK MFG.)
<br /> Cm. 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 B&C,
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D3
<br /> E, Check the appropriate box. �
<br /> . Check the type of MOTOR VEHICLE FUEL.(if brae 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 CONSTRUCTIONITEM ONLY IN BOX A, ,
<br /> 1. Check only one iters 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.LEAS DETECTION SYSTEM
<br /> 1, Circle P for r RIMAFiY,or S for SECONDARY, A primary.and/or secondarry leafs detection system MUST be circled,
<br /> 2. It UNKNOWN,specify or if OTHER, print in space provided.
<br /> 3. If there;s no SECONDARY I..EAK DETECTION SYSTEM,circle NONE.
<br /> 1.INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMATED DATE. LAST USED- MONTH/YEAR(January, 1988 or 01,/88).
<br /> 2, ESTIMATED QUANTITY of SUBSTANCE remaining in tank.tint Gallons)
<br /> 3, WAS TANK FILLED WITH iiNERT MATERIAL,' Check YES'or' 10'.
<br /> PP11t must sign and date form as Indicated.
<br /> IT 1S THE RESP&SIBLITY OF THE LOCAL AGENCY THAT INSPECTSFACILITY/SITE TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION.°T E LOCAL AGENCY ISRESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION
<br /> AND FOR FORWARDING ONE FOR ASSOCIATED F " "( THE FOLLOWING ADDRESS:
<br /> STATE OF CALIFORNIA
<br /> WATER BOARD
<br /> pp�� CONTROL
<br /> PROCESSINGDATA E T
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
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