Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STO AGE TANK PROGRAM <br /> TANK JAN <br /> K P 1,JIT APPLICATION INFORMATION <br /> ria �o <br /> 1l S FWi TIONS FOR COMPLETING THIS FORM <br /> GENERAL INSTRUCTIONS: <br /> 1, One FORM °' shall•be ersrpletcf for etch tr}s'fair all NEW PERMITS, PERMIT CHANGES, <br /> REMOVALS, and/or any ott e,CTA^ -41100f't9A►1-11CN CHANGE. <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 /> 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 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 farm which stores motor vehicle fuel used to <br /> propel farm vehicles. <br /> I.TANK DESCRIPTION--COMPLETE ALL ITEMS-IF UNKNOWN-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.AB70789) <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 /> , Indicate the tank capacity in gallons. (ex.25,000 or 10,000,etc.) <br /> II TANK CONTENTS <br /> A. 1, If MOTOR VEHICLE FUEL,check box 1 and complete items B&C. <br /> 2, It not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. <br /> B3 Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL.(if box 1 is checked in A) <br /> U. 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 /> III,TANK CONSTRUCTION— MARK ONE ITEM ONLY IN BOX A,S,C&0 <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, <br /> . If OTHER,print in the space provided, <br /> IV.PIPING INFORMATION <br /> 1, Circle A it above ground,or U if underground"circle both if applicable. <br /> 2. If UNKNOWN,circle or if OTHER,print its space provided. <br /> V.LEAK DETECTION SYSTEM <br /> 1, Circle P for PRIMARY,or S for SECONDARY. A primary,and/or 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 /> V1. 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.(in Gallons) <br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check YES'or'NO'. <br /> Applicant swat sign and date form as Indicated. <br /> IT IS THE RESPONSISLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF THE <br /> INFORMATION.THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY'INFORMATION BOX <br /> AND FOR FORWARDING ONE FOR "A"ANC ASSOCIATED FOR "B"(s)TO THE FOLLOWING ADDRESS: <br /> STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> 6 <br />