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<br /> UST Operating Permit Application-Tank Information Instructions 40
<br /> (Formerly SWRCB Permit Application Fm B and UPCF Form hwfWro-b)
<br /> r permit changes and any UST system informationchangm Thisformmustbe sub ritalized�n4
<br /> Complete a separate farm for each UST for all new permits,pe olio approval or to making changes.For tanks that are pan or al conB�tp only
<br /> permit or UST system information charges•unless yourl�agencyhon of a separate Tank Information form.For a UST pamenent 46rLVV�,__
<br /> each compartment is considered a sepmate tank and req _rem
<br /> TYPE OF ACTION and Sections t,11,11I,IV, IX.(Note: Numbering of[hese instructions matches the date element numbers
<br /> 430. TYPE OF ACTION-Check the appropriate box to Indican why this form is being submittede the UST. on
<br /> 430a. DATE UST 430b. DATE EXISTING PUSTD SCOVERED--Enter the datethssUST was discoverey!Mier the d,Leave binkf stallattiionrdate its koswn. ,PQ?fL 5
<br /> I. FACILITY ID NUMBER-This space is for agency use only. �
<br /> 3. BUSINESS NAME-Enter she complete facility name.
<br /> mel location of
<br /> 103. BUSINESS SITE ADDRESS-Enter the sheet address of the facility.including building number.if applicable. Thiseddressmut
<br /> the facility.Pot offr"box numbersseed arec c°wh cn
<br /> h the facility is locatele' d•
<br /> 104. CITY-Enter the city or unincorporated
<br /> 432 TANK IDH-Applicant may carni the owumin hidentification number orlove[his space bik The L"al Agency wall assign tha8nntankidentificehon
<br /> number as the mique 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 indfote if the tank is a stud-tone tank or one in a ompmmented 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 jnitiel tank system
<br /> ant covered by this tank form only.
<br /> installation and does not include upgrades or rctrofita which may have been performed later.enter
<br /> for anewmpar anent leave blank.
<br /> 436. TANK CAPACITY IN GALLONS:Enter the tank opacity. Par ompmmont lent tanks,enter dab for the comparnn
<br /> 437. NU ME ER OF COMPARTMENTS IN THE UNIT:If the tank is aomparmnkennrthe total number oYomparmonin the unit
<br /> 439. TANK USE-Check the typo of tank usage.
<br /> 439x. 1f 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 /> 440e. Ifyou choked"Other,Petraleum"specify-the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials
<br /> Busman,plan(HMBP)inventory).
<br /> 440b. If you choked"Other"under Non-petroleum,specify the common name of substance in the space provided(I,&,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 comtrudion"material of the primary containment 04., inner tank wall nearest the hazardous substance
<br /> stored). If the tank material is of listed,check
<br /> eck'Oteontai d specify in the
<br /> espate Pal in the space provided.
<br /> 444a If you checked"Othe{'specity the type primary check'Other'and specify the
<br /> 445. TANK SECONDA�n�O i d A4E above. If the tank fps a'stnB ecwe I tank check�'Nona.nblf the auislos�not loistcdrnment external m,n separate
<br /> from,the p arY
<br /> material in the spa"Provided(e.g..HDPE). ,
<br /> 445s. Ifyou checked"Other"specify th type of secondary onbinmenl in the space provided.
<br /> of roductywaste piping installed in thio tank system. "Safe suction"afar to Piping systems clow gr all
<br /> 452 OVERFILL PREVENRON-Check the boxes)te descrih the types)of ove�ll protection equipment instill � stems month no valves or pumps below grade
<br /> 458. PIPING SYSTEM TYPE-Check the type p
<br /> requimments of 23 CCR§2636(exl)(also known as"European Suction'systems)(i.e.,sloped suction piping ay
<br /> errd only one check valve,looted below end an close as pmdical to the suction pump). Title 23, California Code of Regulations is available online at
<br /> ate.
<br /> 460. PIPING CONSTRUCTION-Indi"te lithe piping is single-welled or douhlo-wallcd,or"othd'.
<br /> 464. PIPINGPIUMARY CONTAINMENT-o`haonsinama Iin the spacetvded �(i.c.,inncr)underground producVweste piping. trench
<br /> 464x. If you checked-Mee,specify the type primary
<br /> 4641 PIPING SECONDARY CONTAINMENT-Check the materials)used to construct the secondary containment system(s)(i e.,secondary piping,
<br /> he
<br /> provided for the product/wast°piping.For secandwallonbigmot ns,c spore provided.
<br /> 464c. if you checked"Otho"specify the type PEary, type P P g/tu
<br /> 4644. Pyou cheURBINBCONTA1NMEt4TSUMPTYPE-tnt Indicate the of i in provided.
<br /> containment sump(s).Check"Noce"if of prcmn.
<br /> 464e-el VENT PRIMARY CONTAINMENT-fC'he'k the
<br /> Ma to thesspxe to Proided.construct the pnmW(i.e..inner)vent piping.Note:Address venting of the tank primary
<br /> Specify Other typo piping.) rovided for
<br /> onNTSE tonlyARY CONused toconstructTAINMENT
<br /> 464F-11
<br /> Ne ventEpiping. ForYsinge-walPips5'tems,teheck t"None." Note:Address venting r the tank primary onbinment'only.)secondary
<br /> Other HP^of
<br /> containment in the spa"provided.
<br /> 4648-g1VR PRIMARY CONTAINMENT-Check the materit(s)umf containmto construct ent the Space(Providedr)vepar recovery piping for tanks without vapor recovery
<br /> piping(e.g..Dieml tanks),chock"Noe." Specify other" g„secondary piping)provided for the
<br /> 464h-hl VR SECONDARY CONTAINMENT-Check the mtersl(s)used n construct the seondaary,containmentcontainment n the space provided.
<br /> vapor recovery piping.For single-wall piping sysnms,check"Normo." Specify Other hP°
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sumP(s).Check"Nona"if not present
<br /> RISER PRIMARY CONTAINMENT-Check the manrial(s)used to construct theprimary(Lo.,inner)piping for all rims(not drop tabes)other than anular
<br /> 4641-j1
<br /> space risers(i.e..rims for filling or gauging of the primary tank). S ci Other of containment in the space provided. sum provided
<br /> of containment in the space provided.
<br /> 464k-kl RISER SECONDARY CONTAINMENT'-Check the metuial(s)used to construct secondary containment System(s)(i.e..second
<br /> piping. Ps
<br /> for the riser piping.For risers without secondary containment,check"None."Specify Other type
<br /> 451ac FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment, tank bottom protection,and fill - If the system
<br /> sumps no
<br /> applicable)aro installed. of dispenser cotainment systam(s)(i.e.,dispenser sumps or Paas). If the system tins o
<br /> 469x. UDC CONSTRUCTION TYPE-Check the box to describe the type spa
<br /> dispensers(e.g.standby generator tank system),check"No Dispenses" Ifthsystembesadispenmr,bolo UDC,check"None-.
<br /> 469b. UDC CONSTRUCTION MATERIAL-heck he bomatex In the space describe s used to construct the UDC.
<br /> 469c. If you checked"Other"specify(h components
<br /> 448. m1 �sCOMPONENT
<br /> ImlelionR means elf'ectric IAll
<br /> iole6on from milcontain SObmkme Fl and ground water.ocExtamples include fiber6 also describe rid n6.talon-metal)c l corrosion soondery
<br /> containment systems which isolate steel components from the sub-aurrece environment,ndinsulatingbtahings, provided. This
<br /> APPLICANT SIGNATURE-Tisa acme person who signs the UST Operating Permit Application-Facility Information Form shell sign in the space
<br /> signature SI certifies - the signer believes that all in
<br /> 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 svan signed.
<br /> 471. APPLICANT NAME-Print Or 472. APPLICANT TITLE-Enter the title tOf the person signing thehe name of the person &fto'rm.e form.
<br /> Rev.(178007)
<br /> UPCF UST-B'-212 ,
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