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STATE OF CALIFOAIA WATER RESOURCES CONOOL BOARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT <br /> `APPLICATION INFORMATION _ a <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "f3" shall be completed for each tank for all NEW PERMITS, IT" CHANGES, <br /> REMOV�LS, and/or any other TANK INFORMATION 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 snaking 3 copies. <br /> TOP OF FORM:" ONLY ONE ITEM" <br /> 1. Mark an(X)in the box next to the item that best describes the reason the fora 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 ars agricultural farm which stores motor vehicle fuel used to <br /> propel farm vehicles. <br /> 1.TANK DESCRIPTION« COMPLETE ALL ITE m IF UNKNOWN d 80 SPECIFY <br /> A. Indicate owners tank ID#- It there is a tank number that is used by.the owner to identity the tank.(ex.AI370789) <br /> S. Indicate the name of the company that manufactured the tank.(ex.ACME TANK MFG.) <br /> C. Indicate the year tank was installed.(ex. 1937) <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&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL,(if box 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 /> III.TANK CONSTRUCTION—MARK ONE ITEM ONLY IN BOX A,B,C <br /> 1. Check only one item in TYPE OF SYSTEM,TALK MATERIAL., INTERIEUR LINING ar1d CORROSION PROTECTION, <br /> 2. If OTHER,print in the spaceprovided. <br /> I .PIPING INFORMATION <br /> 1. Circle"A if above ground,or Vif underground,'circle both if applicable. <br /> , 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 primary.andtdr 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 /> Yla INFORMATION ON TANK PERMANF T"LY CLOSED <br /> 1. ESTIMATED DATE LAST USED- MONTH/YEAR(January,'1938 or 01/88), <br /> 2. ESTIMATED QUANTITY of SUBSTANCE remaining in tank.(in Gallons) <br /> 3. WAS TANK FILLED WITH INERT"MATERIAL? Oheck'Y S'or'NO'. <br /> Applicant must 9190 and datp form as Indicated. <br /> IT IS THE ES I LI F THE LOCAL AGENCY THAT INSPECTS T" E FACILITY/SITE `f Y THE <br /> INFORMATION.THEL L AGENCYI `RESPONSIBLE Y COMPLETION FTHE"L YUSE, L INFORMATION <br /> AND F FORWARDING F ASSOCIATED_ F "B"(9)TO THE FOLLOWING ADDRES a <br /> STATE F PALIFORNIA <br /> C/O <br /> WATERCONTROL BOARD <br /> 1 • m a . • . <br /> DATA PROCESSING <br /> P.O. 52 <br /> PARAMOUNT,CA 90723 <br /> 3-15-88 <br />