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ST-Tank Form Page 1 InVructio Yormerly SWRCB Permit Application Form Complete a separate form for each tank for all new permits, permit changes, or any facility information changes. This form must be submitted within 30 days of permit or facility information changes, unless your local agency requires approval prior to making changes. For compartmentalized tanks, each compartment is considered a separate tank and requires completion of a separate tank form. Please number all pages of your submittal. (Note: Numbering of these instructions follows the UPCF data element numbers on the form.) 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 430. TYPE OF ACTION - Check the reason why this form is being submitted. For amended permits and changes of information, include a brief statement summarizing the amendment or change. 431. LOCATION WITHIN SITE-You may use this space to describe the location of the tank within the facility. 432. TANK ID NUMBER-If the UST owner has assigned an in-house tank ID number to this tank,enter that number in this space. 433. TANK MANUFACTURER-Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK-Check the appropriate box to indicate whether or not the tank is compartmentalized. Each compartment is considered a separate tank. 435. DATE TANK INSTALLED-Enter the year and month the tank was installed. 436. TANK CAPACITY-Enter the tank capacity in gallons. 437. NUMBER OF TANK COMPARTMENTS-If the tank is compartmentalized,enter the number of compartments. 438. ADDITIONAL DESCRIPTION-You may use this space to provide additional tank or location information. 439. TANK USE-Check the substance stored. If motor vehicle fuel,check box 1 and complete item 440,PETROLEUM TYPE. 440. PETROLEUM TYPE-If box 1 in item 439 is checked,indicate the specific type/grade of fuel stored. 441. COMMON NAME-For substances other than motor vehicle fuels,enter the common name of the substance stored. 442. CAS#-For substances other than motor vehicle fuels,enter the CAS(Chemical Abstract Service)number. 443. TYPE OF TANK-Check the type of tank construction. If type of tank is not listed, check 'other" and specify type in the space provided. 444. TANK MATERIAL(PRIMARY TANK) -Check the material of construction of the inner tank(i.e. inner tank wall nearest the hazardous substance stored). If the tank is lined, describe the lining material in item 446,not in this section. If the tank material is not listed,check"other"and specify the material in the space provided. 445. TANK MATERIAL(SECONDARY TANK)-Check material of construction of the tank that provides containment external to, and separate from, the primary containment described above. If the tank material is not listed, check 'other" and specify the material in the space provided.If the tank is a single-wall tank,skip item 445. 446. TANK INTERIOR LINING OR COATING- Check the material of construction of any interior lining or coating in the tank. If unlined,check"unlined." If the type of interior lining or coating is not listed, check"other" and specify the lining material in the space provided. 447. DATE TANK INTERIOR LINING INSTALLED-If applicable,enter the date the tank interior lining was installed. 448. OTHER TANK CORROSION PROTECTION-If any other tank corrosion protection methods are used, check the appropriate boxes to describe them. If methods used are not listed,check'other"and describe in the space provided. 449. DATE TANK CORROSION PROTECTION INSTALLED-If applicable,enter the date tank corrosion protection was installed. 450. YEAR SPILL AND OVERFILL INSTALLED - Check the appropriate boxes to indicate whether drop tube(s), spill containment,and striker plate(s)are installed. In the spaces provided,specify the year each type of equipment was installed. 451. TYPE OF SPILL PROTECTION-Enter the type of spill containment,drop tube,and striker plate installed. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box(es) to describe the type(s) of overfill protection equipment installed. In the space provided,specify the year this equipment was installed. 453. TANK LEAK DETECTION (SINGLE WALL TANKS ONLY) - Check the leak detection system(s) used to comply with monitoring requirements for the tank itself. CHECK ALL THAT APPLY. If you use a leak detection system that is not listed, check'other"and describe the system in the space provided. 454. TANK LEAK DETECTION(DOUBLE WALL TANKS)-For double wall tanks,tanks in vaults,or tanks with a bladder, check the leak detection system(s)used to monitor the tank secondary containment system. CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - Complete this section only if the tank was closed in place. Enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - Complete this section only if the tank was closed in place. Enter the estimated quantity of hazardous substance remaining in the tank(in gallons). 457. TANK FILLED WITH INERT MATERIAL-Complete this section only if the tank was closed in place. Check whether or not the tank was filled with an inert material prior to closure. UPCF hwfwrc-b(1/99)-2/4 http://www.unidocs.org Rev.02/16/00