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STATE OF CALIFORIMA WATER RESOURCES <br /> L BOARD <br /> FORM 'B": UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> GENERAL INSTRUCTIONS <br /> 1. One FORM "B" 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 typo 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 > 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 /> Ia TANK DESCRIPTION—COMPLETE ALL,ITE ®IF IJ m SO SPECIFY <br /> A. Indicate owners tank ID#- It there is a tank number that is used by the owner to identify the tank.( x.AR707 9) <br /> B. Indicate the name of the company that manufactured the tank.(ex.ACME TANK MFC.) <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 /> 11 TANK TT <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items I3&C, <br /> 2. It 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 /> D3 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,B, <br /> 1._Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING l:0 CORROSION PROTECTION, <br /> . If OTHER, print in the space provided. <br /> IV.PIPING INFORMATION <br /> 1. Circle A if above ground,or Uiif 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 primer ; nd/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 /> YI.INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED- MONTH/YEAR(January, 1953 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 must sign and.,date form as Indicated. <br /> : <br /> IT IS THE RESPONSIBLITYF THE LOCAL AGENCY THAT SFE THE All / I'T O VERIFY THE ACCURACY OF THE <br /> INFORMATION.T LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETIONF THE"LOCAL AGENCY USE ONLY"INFORMATION <br /> AND FOR FORWARDING F ASSOCIATED F " "( )TO THE FOLLOWING ADDRESS: <br /> STATE F CALIFORNIA <br /> �R <br /> qWATERCONTROL BOARD <br /> C < e e u a s <br /> DATA PROCESSING <br /> P.O. 527 <br /> PARAMOUNT,CA 90723 <br /> C <br />