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UST Operating Permit Application-TankInformationInstructions ■ ECEIVE.d �:
<br /> (Formerly SWRCB Permit Application Form B and UPCF Form hwfwre-b) - n�fI�sI� fI��QQ
<br /> Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This forth muJ arubMiAEd'o tfdh 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 forth.For a UST cieewvel.G9nallelig,Pnly
<br /> TYPE OF ACTION and Sections 1,I1,111,IV,and IX.(Note: Numbering ofihese instructions matches the data element num tM9"grn.._R
<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-Entetrthe date this UST was itiscovened.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 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 f1-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-Entex 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 initifl tank system
<br /> installation,and does not incl6de upgrades or retrofits which may have been performed later.If this is Por a new installation,leave blank.
<br /> 436. TANK CAPACITY IN GALLONS:Enter the tank capacity. For compartmentalized tanks,enter data for the oompartmentcovered 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. Ifyou checked"Other'specify the type of tank usage in the space provided.
<br /> 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stomd,
<br /> 440a If you checked"Other Petroleum"specify-the common memo of the substance in the space provided(i.e.,the name used in the facility's Hazardous Materials
<br /> Business Plan(HMP)inventory].
<br /> 4406. 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.&.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 lank,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 boxes)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(x)(3)(also khown 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 eelren cora.
<br /> 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-walled,or"other'. -
<br /> 464. PIPING PRIMARY CONTAINMENT-Check the materials)used toconstruct the primary(i.e.,inner)underground product/waste piping.
<br /> 464x. If you checked"Other'specify the typeof 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/waste piping.For single-wall piping systems,check"None."
<br /> 464e. If you checked"Othee,specify the type of secondary containment in the space provided.
<br /> 4644 PIPINGnuREINS CONTAINMENT SUMP TYPE-Indicate the type ofpipfnpfturbine containment sump(s).Check"None"if not present.
<br /> 464ce1 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 systems)(eg.,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 materialist used to construct the primary(Lo,inner)vapor recovery piping. For tanks without vapor recovery
<br /> piping(e.g,,Diesel tanks),check"None." Specify Other type ofcontairment in the space provided.
<br /> 464h-hl VR SECONDARY CONTAINMENT-Check the material(e)used to construct the secondary containment system(s)(c g,secondary piping)provided for the
<br /> vapor recovery piping For single wall piping systems,check"Nona" Specify Other type of containment in the spa"provided.
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate"of transition sump(s).Check"None"if not present.
<br /> 464j.j t 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.,risemfor fillingor gauging of the primary tank). Specify Other"of containment in the space provided.
<br /> 464k-kl RISER SECONDARY CONTAINMENT-Check the material(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-o.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 /> 469x. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispense 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"Othee'specify the construction material in the space provided.
<br /> 448. STEEL COMPONENT PROTECTION-All systems contain some steel components. Check the appropriate box(ea)to describe all corrosion protection
<br /> methods used. "Isolation"means electrical isolation from sail,backfill,and groundwater. Examples include fiberglass cladding non-metallic secondary
<br /> containment systems which isolate steel components from the sub-surfs"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 codifies that the signer believes that all information submitted is true and accurate,and that the UST system is compatible with the.hazardous
<br /> substance stared.
<br /> 470. DATE-Enter the data 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-B-22 Rev.(1 22(107)
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