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JPF <br /> 'STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ' 5��4YUR�gA rgF.. <br /> FORNIV: UNOERGROUND STORAGE TANK PROGRAMTANK TANK'PERMIT APPLICATION INFORMATION <br /> �� ; . <br /> e <br /> GENERAL <br /> INSTRUCTIONS' <br /> 1. One FORM , „ shall: .ecru afet 'd for each tank for.all NEW PERMITS, P IT'CHANGES, <br /> REMOVAL% and/or any otbefTR, O F <br /> 2. This form should be completed by either the, 1T I 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' '. A farm tank is a tank located on an agricultural farm which stores motor vehicle fuel used to <br /> propel farm vehicles. <br /> 1.TANK DESCRIPTIONCOMPLETE LL ITE -I -SO SPECIFY <br /> A. Indicate owners tank I --It there is a tank number that is used by the owner to identify the tank,(ex.A 707 ) <br /> R. indicate the name of the company that manufactured the tank.(ex.ACME TANK G.) <br /> . Indicate the year tank was installed.(ex.1937) <br /> D, Indicate the tank capacity in gallons,(ex_25,000 or 13,439,etc,) <br /> fl TANK CONTE14TS <br /> A. 1, if MOTOR VEHICLE FUEL,check box 1 and complete items � <br /> 2, If not MOTOR VEHI LE FUEL, check the appropriate box in section A and complete items R&D. <br /> E. Check the appropriate box. <br /> C. Check the,type of MOTOR VEHICLE FUEL.(if box 1 is checked in A) <br /> . Print the chemical name of the hazardoussubstance stored in the tank and theC.A.S.If. (Chemical Abstract Service number),if box 1 is <br /> NOT checked in A. <br /> in.TANK CONSTRUCTIITEMONLY IN BOX A,6, <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 /> IV.PIPINGINFORMATION <br /> 1. Circle A if above ground,or U If underground;circle both if applicable. <br /> 2, If UNKNOWN,circle or if OTHER,print inspace 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 /> . If UNKNOWN,specify or if OTHER, print in space provided. <br /> 3. If there is no SECONDARY LEAK DETECTION TION SYSTEM,circle NONE. <br /> I,INFORMATION TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED - MONTH/YEAR(January,1988 or 41 fSS)° <br /> 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> . WAS TANK FILLED WITH INERT MATERIAL? Check'YES`or`f 3'. <br /> Applicant s d date form as Indicated. <br /> IT IS THE RESPONSIBLITY OF THE LOCAL AdENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF T14E <br /> INFORMATION.T LOCAL AGENCY! ESP I E THE COMPLETIONF THE"LOCAL AGENCY USE ONLr INFORMATION BOX <br /> AND � <br /> FOR FORWARDINGE F asASSOCIATEDF "B"(s)TO TEFOLLOWING ADDRESS, <br /> STATE OF CALIFORNIA <br /> WATERE CONTROL BOARD <br /> 6 <br /> CENTERDATA PROCESSING <br /> E2 <br /> PARAMOUNT,CA 90723 <br /> 3-15-6� <br />