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UST Operating Permit Application-Tank Information Instructions
<br /> RECEIVE
<br /> (Formerly S WRCB Permit Application Form B and UPCF Form hwfwto-b) �,1 ^
<br /> Complete a separate farm for each UST for all new permits,permit changes,and any UST system information changes. This form mu b r rime t 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 a4rc.rroo�mW�pooayyn@@m�,e55npytrnanlppized unit,
<br /> each compartment is considered a separate tank and requires completion of a separate Tank Information form.For a UST pe�' �Ct'41I4L rlGs�5t�nly
<br /> TYPE OF ACTION and Sections 1,11,111,IV,end IX.(Moto: Numbering ofthese instructions matches the data element numb PERM. ( �n,�
<br /> 430. TYPE OF ACTION-Check the appropriate,box to indimtewhy this tomo is being submitted.
<br /> 4300. DATE UST PERMANENTLY CLOSED-For reporting closure only:enter the date the USTwas removed or closed an site.
<br /> 430b. DATE EXISTING UST DISCOVERED-Entei the date this UST was discovered.Leave blank if installation daze is known.
<br /> I. FACILITY ID NUMBER-This spam 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 ere not acceptable.
<br /> 104. CITY-Enter the city or unincorporated arca in which the facility is located,
<br /> 431. TANK ID 4-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 most 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 inifig tank system
<br /> installation,and does not incl(sde upgrades or retrofits which may have been performed later.If this is for a new instillation,leave blank.
<br /> 436. TANK CAPACITY IN GALLONS:Enter the tank capacity. For compartmentalized(antes,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 /> 439x. If you checked"Other"Specify the type of tank usage in the spam provided.
<br /> 440. TANK CONTENT'S-Check the specific petroleum or non-petroleum substance stored,
<br /> 4400. 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(Ie.,the name used in the HMBP inventory).
<br /> 443. TYPE OF TANK-Check the box that idm ifes 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 ft tank material is not listed,check'Other"and speoify the material in the spam 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 /> 445x. if you checked"Other"specify the type of secondary containment in the spaceprovided.
<br /> 452 OVERFILL PREVENTION-Check the boxes)to describe the type(s)of overfill protection equipment installed.
<br /> 458. PIPING SYSTEM TYPE-Check the type of product/wasto piping installed in this tank system. "Safe suction'infers to piping systems meeting all
<br /> requirements of 23 CCR§2636(a)(3)(also known M-Eumpm,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 /> 460. PIPING CONSTRUCTION-Indicate if the piping is singlewalled or double-walled,or"other". -
<br /> 464. PIPING PRIMARY CONTAINMENT-Check the materials)wed toconstruct the erimary(i.e.,inner)underground product/waste piping
<br /> 464a If you checked"Other"specify the type of primary containment in the spam provided.
<br /> 464b. PIPING SECONDARY CONTAINMENT-Check the malcrial(s)used to construct the secondary containment systems)(i.e.,Secondary piping,Uach)
<br /> provided for the product/wssto piping For single-wall piping systems,check"None."
<br /> 464c. If you checked'Cather"specify the type ofsecandary containment in the spam provided.
<br /> 4644 PIPING/TURBINE CONTAINMENT SUMP TYPE-Indicate the type ofpipinWhmbino containment sump(s).Check"None"if ret present.
<br /> 464e-c1 V ENT PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(Le.,inner)vent piping. (Note:Address venting of the tank primary
<br /> containment only.)Specify Other type of containment in the spam 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"None," (Note: Address venting of the tank primary containmenr only.)Specify Other type of
<br /> containment in the space provided.
<br /> 464gg1 V R 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),chock"None.'• Specify Other type ofeonlaimnent 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 Forsingle-well 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"Nona'ifnotpresent
<br /> 464j-j 1 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 /> spam rims(i.e..rims for filling or gauging of the primary tank). Specify Other"of containment intha spam provided.
<br /> 464k-ki RISER SECONDARY CONTAINMENT-Check the matedal(s)used to construct secondary containment systems)(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 /> 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)aro installed.
<br /> 469a UDC CONSTRUCTION TYPE-Check the box to describe the typo of dispenser containment systems)(no dispenser sumps or pens). If the system has no
<br /> dispersion Cop.standby generator tank system),check"No Dispensers" Ifthosystemhasadispenser,but no UOQ 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 proration
<br /> methods used. "Isolation"means electrical isolation from soil,backfill,and groundwater, Examplea include fiberglass cladding non-metallic secondary
<br /> containment systems which isolate stat 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 shell 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.hvardous
<br /> substancestared.
<br /> 470, DATE-Enter the date the form wen signed. ,
<br /> 471. APPLICANT NAME-Print or type the name of the person signing the form.
<br /> 472. APPLICANT TTME-Enter the title of the person signing theform.
<br /> UPCF UST-B-212 Rev.(I M007)
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