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UST Operating Permit Application-Tank Inforniiition"'hItstructions
<br /> (Formerly SWRCB Permit Application Fo -- Form )
<br /> � .;
<br /> Complete a form for UST for all permit changes,and any UST system information _ This form must be submitted within 30
<br /> days of
<br /> Permit or UST system infarmstion chaogea,uohss your heel agency requires approval In=to making changes.For teaks that ace part of a co tmtt,-.
<br /> each compartment is considered a seligam tank and requires 001111phdon of a separate Tank Information foim.For a UST permanent closure or rival,Complete ixtiy
<br /> TYPE OF ACTION and Sections 4 II,III,IV,and DL of them inamiations matchas the data element numbers on the form.)
<br /> 430. TYPE OF ACTION-Check the appropriate bmt to indicate why this form is being submitted.
<br /> 430L DATE UST PERMANENTLYCLOSED-For reporting closure only the date the UST was removed or closed on site,
<br /> 430b. DATE EXISTING UST DISCOVERED-Eaw the date this UST was discovervil,Leave blank if installation date is known.
<br /> 1. FACILITY ID NUMBER-Thin space is for use
<br /> 3. BUSINESS NAME-Enter the complete
<br /> 103. BUSINESS Srl'E ADDRESS-Enter the sum address of the filcility,including building number,if applicable. Thisaddress must be the physical location
<br /> .. of
<br /> the facility.Post office box numbers are not
<br /> 104. CITY-Era the city or unincorporated am in which the ilicility is
<br /> 432. TANK ID#Titan may toff the ownces tank identification munber or leave this spate blank.The Local Agency will assign the State tank'
<br /> number as the unique idendfier fa the tank. -
<br /> 433. TANK MANUFACTURER-Eritarthemarmof thecompanythat manulbotured the tank
<br /> 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a one tank or one in a compartmented unit.A separate UST
<br /> Operating
<br /> Permit Application-Tank hifbirmation foam must be submitted for each compwmlcnL
<br /> 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signed-off on fnstaibi of the UST '
<br /> inial and does or Sts which may have been system This is the date of '' tank
<br /> 436. TANK CAPACITY IN GALLONS:Einer If is for the
<br /> new' on,leave blank.
<br /> . For �• for the ce covered by this tank form only..
<br /> 437. NUMBER OF COMPARTMENTS IN THE UNrr.If the tank a a computmem,enter die total number of compartments in the uniL
<br /> 439. TANK USE-Check the type oftank
<br /> 439x. If you the type of tank usage in the space providcil.
<br /> 440. TANK CO =Check the specific petroleum or lemn substance aimed.
<br /> 440x. If you Petroleum"specify the Commoti name of the substatim in the space provided[Le.,the name used in the facility's Haurdous Materials
<br /> Plan P)' ).
<br /> 440b. If you the commonname of substance in the space provided(Le.,the name used in the EMP mventory�
<br /> 443. TYPE OF TANK-Chu&die box that Weinifies the type of
<br /> 444 TANK PRIMARY COM -Cbc&the construction material of the primary co (Lm,inner tank wall neatest thehazardous in*
<br /> stored). If the tank is listed, specify the in the provided .swm
<br /> ._�..._....
<br /> 444x. If you chocked the type of Pm=Y cordiumnant in die spew provided.
<br /> 445. TANK SECONDARY COM -Check the construction material of die secondary commument that provides containment external to,and
<br /> from,the primacy commitment described above.If the tank is a wall tank,check"None." If the material is not listed,check"Other"and the
<br /> material in the space provided(mg,HDPE).
<br /> 4459. If you chocked"Other"
<br /> specify die type®f secondary containment in the space provided.
<br /> 452 OVERFILL PREVENTION-Check the box(es)to s)ofovaaprotection quipmerniostalI
<br /> 458. PIPING SYSTEM TYPE- the type of in this tank system. "Safe suction" refers to piping systems Meawg'wi
<br /> requirements ._.
<br /> of 23 CCR§2636(a)(3)(also known as S )(Le„sh>peed sued pipiing with no valves or pumps below grade
<br /> and only one check valve,located below and as close as FracuW to the pump). Tide 23,California Code of Regulations is available online at
<br /> wwwxalteas.com
<br /> 460. PIPING CONS71RUC17ON-bidicate if the piping is singlowalled or doublowalled,m."o ff.
<br /> 464. PIPING PRIMARY COM -Check the s)used to construct the primary(i.e.,inner)underground product/wasta piping
<br /> 464a. If you specify the type of in the -
<br /> 464b. PIPING SECONDARY COM -Check the s)used to construct the secondary containment s)(Le,secondary piping, ) _
<br /> Provided for the For sings "Nano."
<br /> 4649 If yon chocked rim type of secondary cOOMWNW in tbA spa=provided.
<br /> 4644. PIPINGn URBINE CONTAINMENT SUMP TYPE-bilame the type ofp*mWturbm contanintent sump(s).Check-None"if not present
<br /> 464e-e1 VENT PRIMARY CONTAINMENT`-Check the s)used to c0astruct die primary(Lm,inner)vent piping. (Note:Address venin of the tank
<br /> containment only)Specify type of in the provided B
<br /> 464f-fp VENT SECONDARY COM -Check the s)used to COWMICt the secondary contammag systems)(e g,secondary piping,)provided for
<br /> tato vent piping.For single-wall piping " (Nota Addiress venting of the tank containment only) Specify Other'type of
<br /> Bron in the _.
<br /> 464g-gl VR PRIMARY COM -Check the (Lm,lona)vapor recovery pip& For tanks withon
<br /> (s) to t� vapor recovery
<br /> PIPmB(mB,Diems tankiX " Specify Other type of containment in the space provided s
<br /> 464h-hl VR SECONDARY CONTAINMENT-Check the s)used to construct the secondary containment system(s)(GB-secondary piping)provided for do
<br /> vapor recovery Piping'For gagle-wall Piping check " Specify Other type of containment in the space provided.
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE-Wdmft type oftrangdon smap(s).Check-None"if not
<br /> 464j j 1 RISER PRIMARY CONTAINMENT-Checkthe s)used to• the primary(Le.,ins)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 COM - s)used to 00111itnict secondary containment system(s)(i.e,secondary piping, )provided
<br /> for the rises piping.For ricers without seen "Nom" Specify Other type of co in the space provide&
<br /> 4519-c.FILL COMPONENTS INSTAL.LED- the toshowthat Vill Wftmnmt, tank bottom protection,and fill co (if
<br /> pplicable)are installed
<br /> 469x. UDC CONSTRUCTION TYPE-Chock the box todescribe the type of dispenser cmtdmmeut system(s)(i.e.,dispenser sumps or pans). If the system has no
<br /> dLVensm(e'g,standby generator tank system4 c "No " If the SYSIVID has a dispenser,but no UDC,check"None.
<br /> 469b. UDC CONSTRUCTION MATERIAL-Check the bon to describe the matartals used to eromuuct the UDC.
<br /> 469c. If You checked"Other"specify the construction maurW in the spew provided.
<br /> ® 448. STEEL COMPONENT PROTECTION-All systems contain some steel components, Chock the appropriate box(es)to describe all corrosion
<br /> methods used. "Is0b1ti0e means electrical 1301111JOIR from sA backfill,and F=mdW8W Examples include fiberglass cladding,nolie
<br /> secondary
<br /> containment system which Isolate stoel components from the Albsurface environment,and insulating bushings..
<br /> APPLICANT SIGNATURE-The same person who signs the UST OP=tmg Permit Application-Facility Information Form shall sign in the space provided. This
<br /> signature cxxtifies that the signer believes that all information submitted is trn and accurate,and that the UST system is compatible with the
<br /> hazardous
<br /> substimm gored.
<br /> 470. DATE-End the date the form was signed. -'
<br /> 471. APPLICANT NAME-Print or type the name of the person signing the foam.
<br /> 472. APPLICANT WILE-Enter the title of the parson signing the form.
<br /> UPCF UST B-212
<br /> Rev.(IZPAM
<br />
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