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UST Operating Permit A lication-Tank
<br /> p g pp Information Instruchons
<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 a 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 /> I. 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 initial 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 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 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.calregs.com.
<br /> 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-wailed,or"other".
<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 /> 4644. 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 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 /> 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"None"if not present.
<br /> 464j ji 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 TITLE-Enter the title of the person signing the form.
<br /> UPCF UST-11-2/2 Rev.(12/2007)
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