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UST Operating Permit Application - Tank Information Instructions
<br />(Formerly SWRCB Permit Application Form B and LIKE Form hwfwrc-b)
<br />Complete a separate form for each UST for all new permits, permit changes, and any UST system mico mtion changes. This form most 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 part 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, II, III, IV, and IX. (Note: Numbering of these instructions matches the data element numbers on the form.)
<br />430. TYPE OF ACTION -Check the appropriate box to indicate by this form is being submitted.
<br />430& 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 />1. FACILITY ID NUMBER- This space is for agency use only.
<br />3. BUSINESS NAME- Enter the complete facility name.
<br />103. BUSINESS SITE ADDRESS - Enter the sheet address of the facility, including building number, if applicable. This address most be the physical location of
<br />the facility. Post office box numbers are not acceptable.
<br />104. CfIY - Enter the city or unincorporated area in which the facility is located.
<br />432. TANK ID N -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 talc.
<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 stand-alone tank or one in a compartmented unit A separate UST Operating
<br />Permit Application -Tank Information form must be submitted for each comparnnrnt.
<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 jaijw tank system
<br />installation, and does trot include upgrades or retrofit 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 tanks, enter data for the compartment covered by this tank form only.
<br />437. NUMBER OF COMPARTMENTS IN THE UNIT: If to tank is a compartment, enter to total number of compartments in to unit.
<br />439. TANK USE- Check to type of tank usage.
<br />439a. If you checked "Other" specify the type of tank usage in the space provided.
<br />440. TANK CONTENTS - Check to specific petroleum or non -petroleum substance stored.
<br />440a If you checked "Other 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 />4406. If you checked "Othef under Non -petroleum, specify the common name 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 />stored). If the tank material is not listed, check "Other" and specify the material in the space provided
<br />444x. If you checked "Other" specify the type of primary containment in to 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 (mg., HDPE).
<br />445a If you checked "Other" specify to type of secondary containment in to space provided.
<br />452 OVERFILL PREVENTION -Check the boxes) to describe the type(s) of overfill protection equipmem installed.
<br />458. PIPING SYSTEM TYPE - Check to type of product/waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all
<br />requirements of 23 CCR §2636(a)(3) (also known as "European Suction" systems) (i.e., sloped suction piping systems with no valves or pumps below grade
<br />and only me 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.calreas com.
<br />460. PIPING CONSTRUCTION -Indicate if the piping is single -walled or double -walled, or "other".
<br />464. PIPING PRIMARY CONTAINMENT- Check the material(s) used to construct the primary (i.e., inner) underground product/wasm piping.
<br />464a If you choked "Other" specify the type of primary containment in the space provided
<br />464b. PIPING SECONDARY CONTAINMENT - Check the material(s) used to construct the secondary containment sysmm(s) (i.e., secondary piping, trench)
<br />provided for to product/waste piping. For single wall piping systems, check "None."
<br />464c. If you checked "Other" specify the type of secondary containment in to space provided
<br />4644. PIPING/I'URBINE CONTAINMENT SUMP TYPE - Indicate the type ofpiping/mrbine containment sump(s). Check "None" if not present.
<br />464"1 VENT PRIMARY CONTAINMENT - Check the matmal(s) used t 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 to space provided.
<br />4646-h1 VR SECONDARY CONTAINMENT -Check the materialist 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 - Check to material(s) used t construct the primary (ic., inner) piping for all risers (not drop tubes) other than annular
<br />space risers (i.e., 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 in construct secondary containment systems) (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 />45la-c. 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 systems) (i.e., dispenser sumps or Pars). 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 />4696. UDC CONSTRUCTION MATERIAL- Check to box to describe the materials used to construct the UDC.
<br />469c. If you checked "Other" specify the contraction material in the space provided
<br />448. STEEL COMPONENT PROTECTION - All systems contain some steel components. Check the appropriate box(es) to describe all corrosion protection
<br />methods used. "Isolation" means electrical isolation from and, backfill, and groundwater. Examples include fiberglass cladding, non-metallic secondary
<br />containment systems which isolate steel components from the subsurface 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 />signatme certifies that the signer believes that all information submitted is tate and accurate, and that the UST system is compatible with the hazardous
<br />substance stored.
<br />470. DATE - Enter the date the forth was signed.
<br />471. APPLICANT NAME - Print or type the name of the person signing the form.
<br />472. APPLICANT TITLE - Enter to title of the person signing the form.
<br />UPCF UST -B - 2/2
<br />Rev. (1212007)
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