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UST Operating Permit Applica 'on - 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 part of a compartmentalized unit,
<br />each compartment is considered a separate tank and requires completion of a separate Tank Information form. For UST permanent closure or removal, complete only
<br />TYPE OF ACTION and Sections I, 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 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 />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 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 ID # -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 tank.
<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 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 i ' 'al 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 tanks, enter data for the compartment 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 />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 Materials
<br />Business Plan (HMBP) 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 containnicrtt (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 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., 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 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.calres.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/waste piping.
<br />464a 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 -e 1 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 />4648-g1 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 />464i. VENT PIPING TRANSITION SUMP TYPE - Indicate type of transition sump(s). Check "None" if not present.
<br />464j jl RISER PRIMARY CONTAINMENT- Check 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.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) provided
<br />for the riser piping. For risers without secondary containment, check "None." Specify Other type of containment in the space provided.
<br />451a -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 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 UDC.
<br />469c. 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 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 Information Form shall sign in the space provided. This
<br />signature certifies that the signer believes that all information submitted is true and accurate, and that the UST system is compatible with the hazardous
<br />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 TIME - Enter the title of the person signing the form.
<br />UPCF UST -B - 2/2
<br />Rev. (1212007)
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