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UPCF UST Operfag Permit Application - Tank Infora-on Instructions
<br />(Formerly SWRCB Permit Application Form B and UPCF Form hwfwrc-b)
<br />Complete a separate Tank Information form for each UST for all new permits, permit changes, and any UST system information changes. This form must be submitted
<br />within 30 days of permit or UST system information changes, unless your local agency requires approval prior to making changes. For tanks that are part of a
<br />compartmentalized unit. each compartment is considered a separate tank and requires completion of a separate Tank Information form. For a UST closure or removal,
<br />complete only TYPE OF ACTION and Sections I, II, 111, IV, and IX. (Note: Numbering of these instructions matches the UPCF data element numbers on the form.)
<br />430. TYPE OF ACTION - Check the appropriate box to indicate why this form is being submitted.
<br />430x. 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 street address of the facility, including building number, if applicable. This address must be the physical location
<br />of the facility. Post office box numbers are not acceptable.
<br />104. BUSINESS SITE CITY - Enter the city or unincorporated area in which the facility is located.
<br />432. TANK ID # - Enter a unique number used to identify the tank. This number may be assigned by the UST owner/operator or the Unified Program Agency.
<br />433. TANK MANUFACTURER - Enter the name of the company that manufactured the tank.
<br />434. NUMBER OF TANK UNITS. Check the appropriate box to indicate if the tank is a stand-alone tank or one of two or more compartments in a tank system.
<br />A separate UST Operating Permit Application - Tank Information form 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 iRM 'Mtank 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 tanks, enter data for the compartment covered by this tank form only.
<br />437. NUMBER OF TANK COMPARTMENTS: If the tank is a compartment; enter the total number of compartments in the UST.
<br />439. TANK USE - Check the 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 the 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
<br />Materials Business Plan (HIvtBP) inventory].
<br />440b. If you checked "OTHER" 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 />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
<br />separate 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
<br />specify the material in the space provided (e.g., HDPE).
<br />445a. 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 type(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 §2636(a)(3) (also known as "European Suction" systems) (i.e., sloped suction piping systems with no valves or pumps below
<br />grade 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
<br />at www.calregs.com.
<br />464. PIPING PRIMARY CONTAINMENT - Check the material(s) used to construct the primary (i.e., inner) underground product/waste piping.
<br />464x. If you checked "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 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/TURBINE CONTAINMENT SUMP TYPE - Indicate the type of piping/turbine containment sump(s). Check "NONE" if not present.
<br />464e -el. VENT PRIMARY CONTAINMENT - Check the material(s) used to construct the primary (i.e., inner) vent piping. (Note: Address venting of the tank
<br />primary 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
<br />for the vent piping. For single-wall piping systems, check "None." (Note: Address venting of the tank primary containment only.) Specify OTHER type
<br />of 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
<br />recovery 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
<br />the vapor recovery piping. For single-wall piping systems, check "None." Specify OTHER type of containment in the space provided.
<br />464i. VENT PIPING TRANSITION SUMP TYPE - Indicate type of transition sump(s). Check "NONE" if not present.
<br />464j -j 1. RISER PRIMARY CONTAINMENT - Check the material(s) used to construct the primary (i.e., inner) piping for all risers (not drop tubes) other than
<br />annular 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 to construct secondary containment system(s) (i.e., secondary piping, sumps)
<br />provided for the riser piping. For risers without secondary containment, check "None." Specify OTHER type of containment in the space provided.
<br />451 a -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 />469x. 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
<br />no 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 UDC.
<br />469c. If you checked "OTHER" specify the type of UDC construction 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 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 Form shall sign in the space provided. This signature
<br />certifies that the signer believes that all information submitted is true and accurate, and that the UST system is compatible with the substance stored.
<br />470. DATE - Enter the date the form was signed.
<br />471. APPLICANT NAME - Print or type the name of the person signing the form.
<br />472. APPLICANT TITLE - Enter the title of the person signing the form.
<br />UPCF UST -B Rev. (12/2007) - 2/2 www.unidoes.org
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