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<br /> APPLICANT NAME(print) Bob M. Kimball °'h' APPLICANT TITLE RME,Authorized Agent for Caltrans d1s
<br /> UST Operating Permit Application—Tank Information Instructions
<br /> (Formerly SWRCB Permit Application Form B and UPCF Form hwfwrc-b)
<br /> Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This form must be submitted within 30 days of
<br /> permit or UST system information changes,unless your local agency requires approval prior to making changes. For tanks that are par[of a compartmentalized unit,
<br /> each compartment is considered a separate tank and requires completion of a separate'Tank Information form.For a UST permanent closure or removal,complete only
<br /> TYPE OF ACTION and Sections 1,11,III,IV,and IX.(Note: Numbering of these instructions marches the data element numbers on the form,)
<br /> 430. TYPE OF ACTION—Check the appropriate box to indicate why this form is being submitted.
<br /> 430a. DATE UST PERMANENTLY CLOSED—For reporting closure only:enter the date the UST was removed or closed on site.
<br /> 430b. DATE EXISTING UST DISCOVERED—Enter the date this UST was discovered leave blank if installation date is known.
<br /> I, FACILITY ID NUMBER—This space is for agency use only.
<br /> 3. BUSINESS NAME—Enter the complete facility time.
<br /> 103. BUSINESS SITE ADDRESS—Enter the street address of the facility,including building number,if applicable. This address must be the physical location of
<br /> the facility.Post office box numbers are not acceptable.
<br /> 104. CITY—Enter the city or unincorporated area in which the facility is located.
<br /> 432. TANK TD M—Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the State tank identification
<br /> number as the unique identifier for the utak.
<br /> 433. TANK MANUFACTURER—Enter the name of the company that manufactured the tank.
<br /> 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a sland-alone lank or one in a compartmented unit.A separate USTOperating
<br /> Permit Application—Tank Information forth must be submitted for each compartment.
<br /> 435. DATE UST SYSTEM INSTALLED—Enter the date the local agency signed-off on installation of the UST system. This is the date of injIW tank system
<br /> installation,and does not include upgrades or retrofits which may have been performed later.If this is for a new installation,leave blank.
<br /> 436. TANK CAPACITY IN GALLONS:Enter the tank capacity. For compartmentalized ranks,enter data for the cumpartment covered by this tank form only.
<br /> 437. NUMBER OF COMPARTMENTS IN THE UNIT:If the tank is a compartment,enter the total number of compartments in the unit.
<br /> 439. TANK USE—Check the type of tank usage.
<br /> 439x. If you checked"Other"specify the type of tank usage in the space provided
<br /> 440. TANK CONTENTS—Check the specific petroleum or non-petroleum substance stored,
<br /> 440a. If you checked"Offer Petroleum"specify the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials
<br /> Business Plan(HMBP)inventory].
<br /> 440b. If you checked"Other'under Non-petroleum,specify the common time of substance in the space provided(i.e.,the name used in the HMBP inventory).
<br /> 443. TYPE OF TANK—Check the box that identifies the type of tank.
<br /> 444. TANK PRIMARY CONTAINMENT—Check the construction material of the primary containment(i.e., inner tank wall nearest the hazardous substance
<br /> j stored). If the tank material is not listed,check"Other"and specify the material in the space provided.
<br /> 444a If you checked"Other"specify the type of primary containment in the space provided.
<br /> 445. TANK SECONDARY CONTAINMENT—Check the construction material of the secondary containment that provides containment external to,and separate
<br /> from,the primary containment described above. If the tank is a single-wall tank,check"None." If the material is not listed,check "Other"and specify the
<br /> material in the space provided(e.g.,HOPE).
<br /> 445x. If you checked"Other"specify the type of secondary containment in the space provided.
<br /> 452 OVERFILL PREVENTION—Check the box(es)to describe the typo(s)of overfill protection equipment installed.
<br /> 458. PIPING SYSTEM TYPE—Check the type of product(waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all
<br /> requirements of 23 CCR 42636(a)(3)(also known as"European Suction"systems)(i.e..sloped suction piping systems with no valves or pumps below grade
<br /> and only one check valve, located below and as close as practical to the suction pump). Title 23,California Code of Regulations is available online at
<br /> www calrevs.com.
<br /> j 460. PIPING CONSTRUCTION-Indicate if the prying is single-walled or double-welled,or"other'.
<br /> 464, PIPING PRIMARY CONTAINMENT—Check the material(s)used to construct the primary(i.e..inner)underground product/waste piping.
<br /> 464a If you checked"Other'specify the type of primary containment in the space provided.
<br /> 4646. PIPING SECONDARY CONTAINMENT— Check the material(s) used to construct the secondary containment system(s) (i.e.,secondary piping, trench)
<br /> provided for the product/waste piping.For single-wall piping systems,check'None."
<br /> 464c. If you checked"Other'specify the type of secondary containment in the space provided.
<br /> 464d. PIPING?URSINE CONTAINMENT SUMP TYPE—Indicate the type of piping/turbine containment sump(s).Check"None'if not present.
<br /> 464ec1 VENT PRIMARY CONTAINMENT—Check the material(s)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of the tank primary
<br /> containment only.)Specify Other type of containment in the space provided.
<br /> 464f-fl VENT SECONDARY CONTAINMENT—Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for
<br /> the vent piping. For single-wall piping systems, check "None" (Note: Address venting of the tank primary containment only.) Specify Other type of
<br /> containment in the space provided.
<br /> 464g-gl VR PRIMARY CONTAINMENT—Check the material(s)used to construct the primary(i.e.,inner)vapor recovery piping. For tanks without vapor recovery
<br /> piping(e.g,Diesel tanks),check"None." Specify Other type of containment in the space provided.
<br /> 464h-hl VR SECONDARY CONTAINMENT—Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for the
<br /> vapor recovery piping.For single-wall piping systems,check"None." Specify Other type of containment in the space provided.
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE—Indicate type of transition sump(s).Check"None"if not present.
<br /> 464j jl RISER PRIMARY CONTAINMENT—Clieck the material(s)used to construct the primary(i.e.,inner)piping for all risers(not drop tubes)other than annular
<br /> Space risers(i C..risers for filling or gauging of the primary tank). Specify Other type of containment in the space provided.
<br /> 464k-kl RISER SECONDARY CONTAINMENT—Check the material(s)used to construct secondary containment system(s)(i.e.,secondary piping,sumps)provided
<br /> for the riser piping.For risers without secondary containment,check"None." Specify Other type of containment in the space provided.
<br /> 451ac. FILL COMPONENTS INSTALLED—Check the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if
<br /> applicable)are installed.
<br /> 469a UDC CONSTRUCTION TYPE—Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps or pans). If the system has no
<br /> dispensers(e.g.,standby generator tank system),check"No Dispensers." If the system has a dispenser,but no UDC,check"None".
<br /> 469b. UDC CONSTRUCTION MATERIAL—Check the box to describe the materials used to construct the CDC.
<br /> 469a If you checked"Other"specify the construction material in the space provided.
<br /> 448. STEEL COMPONENT PROTECTION—All systems contain some steel components. Check the appropriate busies)to describe all corrosion protection
<br /> methods used. 'Isolation"means electrical isolation from soil, backfill, and groundwater, Examples include fiberglass cladding,non-metallic secondary
<br /> containment systems which isolate steel components from the sub-surface environment,and insulating bushings.
<br /> APPLICANT SIGNATURE—The same person who signs the UST Operating Permit Application—Facility Information Form shall sign in the space provided. This
<br /> signature cenifies that the signer believes that all information submitted is true and accurate, and that the US•f system is compatible with the hazardous
<br /> substance stored.
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<br /> ' UPCF UST-B-2/3 Rev.(12/2007)
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