|
UST Operating Permit Application-TankInformationInstructions
<br /> (Formerly SWRCB Pcrmit Application Form B and UPCF Form hwfwro-b)
<br /> Complete a separate form for each UST far all new permits,permit changes,and"USTsystem information changes. This form mu n 30 days of
<br /> permit or UST system information changes,unless your local agency requires approval prim to making changes.For tanks that aro art of a compartmentnl irtd unit,
<br /> each compartment is considered a separate tank end requires completion of a separate Tank Information forth.For a UST permanent clos�rrrreemfoy@I-cwttYa my
<br /> TYPE OF ACTION and Sections 1,11,III,IV,and TX.(Note: Numbering of these instructions matches the data clement numbers apEURtMr^�IS�PRI�lCr��"'
<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:entertho datetho USTwas removed or closed on site.
<br /> 4306. DATE EXISTING UST DISCOVERED-Enter the 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. 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 offim box numbers are not acceptable.
<br /> 104. CITY-Enter the city or unincorporated area in which the facility is located.
<br /> 432. TANK m#-Applicant may enter the owner's tank identification number or leave this spats 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 /> Penn it Application-Tank Information form must be submitted for each compartment.
<br /> 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signedbff on installation of the UST system. This is the date of initial tank system
<br /> installation,and does not it elbde upgrades or retrofits which may have been performed later.If this is for anew 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 TWIT: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 /> 439x. If you checked"Othee,specify the type of tank usage in the space provided.
<br /> 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored,
<br /> 440x. 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 OFTANK-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 singeo-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 /> 445x. If you checked"Other"specify the type of secondary containment in the space provided.
<br /> 452 OVERFILL PREVENTION-Check the box(m)to describe the type(s)of overfill protection equipment installed.
<br /> 458. PIPING SYSTEM TYPE-Check the typo of product/waste piping installed in this tank system. 'Safe suction"refers to piping systems meeting all
<br /> requirements of 23 CCR§2636(aX3)(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 m close as practical to the suction pump). Title 23,California Code of Regulations is available online at
<br /> a
<br /> 460. PIPING CONST RUCONTAINMEN-Cpipinge singlel(s)usedtocblo-uctth,or other". ' .
<br /> 464. PIPING PRIMARY COMATNMENT-Cheek[ha mnterial(s)usedroconstnct the primary(i.e.,inner)underground product/waste piping
<br /> 464x. if you checked"Othee,specify me type of primary containment in the space provided.
<br /> 464b. PIPING SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment systems)(im.secordery piping,trench)
<br /> provided for the producUwasta piping.For single-"I piping systems,check"None."
<br /> 464c. If you checked"Other"specify the type of secondary containment in the space provided.
<br /> 464d. PIPINGTURBINE CONTAINMENT SUMP TYPE-Indicate the type ofpipinglurbine containment sump(s).Check"None'ifnot present.
<br /> 464ee I VENT PRIMARY CONTAINMENT-Check the materials)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of diatonic 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 systems)(e.g.,secondary piping,)provided for
<br /> the vent piping. For single-wall piping systems,check"Nona." (Note: Address venting of the tank primary containment only.)Specify Other type of
<br /> 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 recovery
<br /> piping(e.g_Diesel tanks).check"Norm" Specify Other type of containment in the space provided.
<br /> 464h-hI VR SECONDARY CONTAINMENT-Check the malm ial(i)used to construct the secondary containment system(s)(mg.,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"Nora'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 Oct drop lubes)other than annular
<br /> space risen(i.e.,rims for filling or gauging of the primary tank). Specify Other type of containment in the space provided.
<br /> 464k-k1 RISER SECONDARY CONTAINMENT-Check the matcnial(s)used to construct secondary containment system(s)(i.e.,seco dwy piping sumps)provided
<br /> for the rise 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)we 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 On
<br /> dispensers(a.&.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 concoct the UDC.
<br /> 469e. 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 boxes)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 /> cmntainment systems which isolate steel components from the sub-surfsre environment and insulatingbushings.
<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 but and accurate,and that the UST system is compatible with the hazardous
<br /> substance stored.
<br /> 470. DATE-tinter the data the form ores signed.
<br /> 471. APPLICANT NAME-Print or type the name of the person signing the form.
<br /> 472. APPLICANT TITLE-Enter the tide of the person signing theform.
<br /> UPCF UST-8-212 Rev.(1280(17)
<br />
|