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a <br /> STATE`OF CALIFOROA WATER <br /> FORM $ #� <br /> wUNDERGROUND STORAGE TANK PROGRAM <br /> PERMITTANK TANK I <br /> INSTRUCTIONS <br /> GENERAL INSTRUCTIONS: <br /> 1. One FIRM "R" shall be completed for each tank for all NEW PERMITS, IT CHANGES, <br /> REMOVALS, and/or any other TANK INFORMATION <br /> 2. This fora 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 IT 94 <br /> 1. Mark an(X)in the box next to the item that best describes the reason the term is being completed. <br /> 2. Indicate the Facility/Site name where the tank is installed. <br /> 3. 1s 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 /> 1.TANK DESCRIPTIONCOMPLETE LL IT -IFU ffi SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank.(ek:'AR707 9) <br /> R. Indicate the name of the company that manufactured the tank.(ex.ACME TAMC MFC .) <br /> C. Indicate the year tank was installed.(ex. 1937) <br /> U. Indicate the tank capacity in gallons,(ex.25,000 or 10,000,etc.) <br /> I TANK CONTENTS <br /> A: 1. If MOTOR VEHICLE FUEL,check box 1 and complete items S&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. <br /> & Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL.(if box 1 is checked in A) <br /> D7 "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,8, <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 in space provided. <br /> V.LEAK DETECTIONSYSTEM <br /> 1. Circle lP 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 /> il.INFORMATION ON TANK PERMANENTLYE IN PLACE <br /> 1, ESTIMATED DATE LAST USED- MONTH/YEAR(January, 1933 or 01/88), <br /> 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> 3. WAS TAMC FILLED WITH INERT MATERIAL? Check'YES`or'NO <br /> Applicant must s19p and#ateform Indicated. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE T VERIFY THE ACCURACY OF THE <br /> INFORMATION.T LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCALAGENCY USE ONLr INFORMATION BOX <br /> AND FOR FORWARDING F "A"AND ASSOCIATED F EB "( )TO THE FOLLOWING SS: <br /> STATE F CALIFORNIA <br /> WATERT" L BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING T <br /> P.O. 52 <br /> PARAMOUNT,CA 90723 <br />