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UST Operating Permit Application-Tank Information Instructions O
<br /> (Formerly S WRCB Permit Application Foran B and UPCF Form Were-b)
<br /> Complete a separate farm for each UST for all"pans^Its,permit cha^8, and any UST system information changes. This form must be huh days of
<br /> permit or UST system information changes,unless your local agency requires approval prior to making changes.For tanks that ora part
<br /> ntelized unit,
<br /> each compartment is considered a separate tank and requires completion of a separate Tank Information form.Fara UST caberspwot or &I.can ty only
<br /> TYPE OF ACRON and Sections 1,11,111,[V,and IX.(Note: Numbering ofthese instructions matches the data element numbers r \ ���Vv"_
<br /> 430. TYPE OF ACTION-Check the appropriato box to indicate why this form is being submitted. \ �
<br /> 4305. DATE UST PERMANENTLY CLOSED-For reporting closure only:enter the date the UST was removed or closed on site. lP
<br /> 430b. DATE EXISTING UST DISCOVERED-Enterthe date this UST was discovered.Leave blank if installation date is known.
<br /> I. FACILITY to NUMBER-This space is for agency use only-
<br /> 3.3. BUSINESS NAME-Enterthe complotefboility Tomo. ,ifapplimble. 'Nis address muste@IfyS
<br /> 103. BUSINESS SITE ADDRESS-Enter the street address ofthc tkcility,including building numbertml location of
<br /> the facility.Post office box numbers are not W'Deplable.
<br /> 104. CITY-Enter the city or unincorporated arm in which the facility is located. .
<br /> 432. TANK to N-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-nWd tank system
<br /> installation,and does not indfide upgrades or retrofits which may have been performed later.Ifthis 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:Ifthe tank is a compartment,enter the total number ofoomparbnents in the unit.
<br /> 439. TANK USE-Check the type oftank usage.
<br /> 439a. If you checked"Other"specify the type of reek usage in the space provided.
<br /> 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored,
<br /> 440x. If you checked"Other,Pctrokum"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 /> 4406. Ifyou 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 oftank.
<br /> 444. TANK PRIMARY CONTAINMENT-Check the construction material of the primary containment(i.e., inner tank well nearest the hawdous substance
<br /> stored). Ifthe tank material is cwt listed,check-Other'and specify the material in the space provided.
<br /> 444a. if you checked"Other"speeitydue type of primary containment in the spam provided.
<br /> 445. TANK SECONDARY CONTAINMENT-Check the construction material of the secondary containment that provides containment extemel to,and separate
<br /> from,the primary containment described above. if the tank is a single-wall tank check"None." If tha material is not listed,check"Other"and specify the
<br /> matedal in the space provided(e.g..HDPE).
<br /> 445a. Ifyou checked"Other"specify the type ofsecondary containment in the spam provided. ,
<br /> 452 OVERFILL TE TYPE-Check
<br /> the tox(w)to describe the of productywaste pili-n)installed ifoverfill n tthist'on tankk system. "Safe
<br /> i"Safe suction" refen to piping system mating all
<br /> 458. PIPING SYSTEM TYPE-Check the typoP piping
<br /> requirements of 23 CCR$2636(e)(3)(also known as"European Sutton"systems)(i.a,sloped suction piping systems with no valves or pumps below Bade
<br /> and only one check valve,located below and n close as practical to the suction pump). Title 23.California Code of Regulations is available online at
<br /> .tom,
<br /> 460. PIPING PRIMARY
<br /> -Che piping enatlal(s)used
<br /> or dto construct
<br /> hepri other'.
<br /> 464, PIPING PRIMARY CONTAINMENT-Checkthe mekrisl(s)used to construct tha primary(i.a.,inner)underground producVwaste piping.
<br /> 464a. Ifyou checked"Other'specify the type of primary containment in the space provided.
<br /> 4646. _PIPING SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment systems)(i.e.,secondary piping,trench)
<br /> provided for the product/yvaste piping.For single-wall pipingaystems,clock"None."
<br /> 464c. Ifyou checked"Othcr'speeify the type ofsecondary containment in the space provided.
<br /> 4644. PIPING/TURBINE CONTAINMENT SUMP TYPE-Indicate the type ofpipingthsrbim containment sump(s).Check"Nom"ifrat Iument.
<br /> 464c-el VENT PRIMARY CONTAINMENT-Check the material(s)used to aaastruct the prim@ry(to.,inner)vent piping. (Note:Address venting of the tank primary
<br /> containment only.)Specify Other type ofect uainment 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 /> 464g-gi VR PRIMARY CONTAINMENT-Check the materialist used to construct the primary(i.e.,inner)vapor recovery piping For tanks without vapor recovery
<br /> piping(ag.,Diesel tanks),check"Nomo." Specify Other type ofcontainment in the space provided. provided for the
<br /> 464h-hl VR SECONDARY CONTAINMENT-Check the material(i)used m tem
<br /> wasbrWt the secondary containment syss)(e.g.,secondary piping)Prov
<br /> vapor recovery piping.For singia-wall piping systems,check"Nona." Specify Other type of containment in the space provided.
<br /> VENT PIPING TRANSITION SUMP TYPE-Indicate type oftransitim sump(s).Check"None"What pramt
<br /> 464i.
<br /> 464j-jl RISER PRIMARY CONTAINMENT-Check the ma[eriaits)used to construct the primary(i.e.,inner piping
<br /> for all risen(rot drop Who)other than annular
<br /> space risers(i.e..risen for filling or gauging of the primary tank). Specify Other type of containment in tln space provided.
<br /> 464k-ki RISER SECONDARY CONTAINMENT-Check the materials)wed to construct secondary coon�eo mem systnt em(s)(St,.pe�secoVdd aPIPi^8.warps)provided
<br /> for the riser piping For risers without secondary containment,check"None,"Specify Other type
<br /> 451 ec. FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment. tank bottom protection,and fill containment sumps(if
<br /> applicable)ere installed.
<br /> 469x. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps at pans). If the system has no
<br /> dispensers(e.g,standby generator tank system),check"No Dispensers." If the system hes a dispenser,but no UDC,check"None'.
<br /> 4696. 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 spent)provided.
<br /> EL COMPONENT PROTECTION-All systems contain some steel components. Check the appropriate boxiest to describe all cortosion protection
<br /> 448. STEEL
<br /> used. "imp T PR means electrical imlatian from mil,backfill,and groundwater- Examples include fiberglass cladding,non-metallic secondary
<br /> widcontainment systems which isolate steel components from the stib-surface environment,and imvlafngbushings.
<br /> APPLICANT SIGNATURE-The same person who signs the UST Operafing Permit Application-Facility Information Form shall sign in the space provided. This
<br /> signature certifies that the signer believes that all information submitted is We and accurate,and that the UST system is compatible with the,hazardous
<br /> substarwestored.
<br /> 470. DATE-Enter the data the form was signed.
<br /> 471. APPLICANTNAME-Print or type the name of the person signing the form.
<br /> 472. APPLICANT TITLE-Enter the title ofthe Person signing theform.
<br /> Rev.(12!1007)
<br /> UPCF UST-B--22
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