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<br /> UST Operating Permit Application-Tank Information Instructions
<br /> (Formerly S WRCB Permit Application Form B and UPCF Form hwfwrc-b)
<br /> Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This form must be submitted within 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 comparane ized unit,
<br /> each comperfitrnt is considered a separate tank and requires completion of a separate Tank Information forth.For a UST permanent closure or rcar plate only
<br /> pv
<br /> TYPE OF ACTION and Sections 1,11,Ill.IV,and IX.(Note: Numbering ofthese instructions matches the data element numbers on the form.) p
<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-Enter the date this UST was discovered.Leave blank ifingelation dale is knowrL4�ia 45
<br /> I. FACILITY ID NUMBER-This space is for agency use only.
<br /> 3. BUSINESS NAME-Entorthe complete facilityname, t Q r
<br /> 103. BUSINESS SITE ADDRESS-Enter the street address of the facility,including building number,ifapplicable. Th am at
<br /> hamuat the physi n 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 N-Applicant may enter the owner's took identification number or leave this space blank.The Local Agency will assign she fication
<br /> number as the unique identifier for the lank. aL -,`
<br /> 433. TANK MANUFACTURER-Enter the name ofthe company that manufactured the wk. rj`ece.
<br /> 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone tank or one in a compartmented u�(nit A3epante 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 initial tank system
<br /> installation,and does not include upgrades or retrofits which may have been performed later.If this 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 numberofcompartments in the unit.
<br /> 439. TANK USE-Check the type of lank usage.
<br /> 439a. If 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 /> 440a. 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. 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 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 /> 444a. Ifyou 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"Nora." 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"amity the type of secondary containment in the space provided.
<br /> 452 OVERFILL PREVENTION-Check the box(es)to describe the type(s)ofovefiill 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 system 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 as close as practical to the suction pump). Title 23,California Code of Regulations is available online at
<br /> www.ca(reg9 con.
<br /> 460. PIPING CONSTRUCTION-Indicate ifthe piping is single-walled or double-walled,Or"other".
<br /> 464. PIPING PRIMARY CONTAINMENT-Check the material(s)wed to construct the primary(i.e..inner)underground product/waste 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 system(s)(i.e.,secondary piping,march)
<br /> provided for the product/waste piping.For single-wall piping systems,check"None."
<br /> 464e. If you checked"Other`specify the type of secondary containment in the space provided.
<br /> 464d. PIPING/ URBINS CONTAINMENT SUMP TYPE-Indicate the type ofpipingkurbine containment sump(s).Check"None"if not present.
<br /> 464e-el 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 ofcontainment 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 singlo-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-gl VR PRIMARY CONTAINMENT-Check the materialist used to construct the primary(i.e..inner)vapor recovery piping. For tanks without vapor recovery
<br /> piping(e.g,Diem]tanks),check"Nora." Specify Other type ofcontainment in the space provided.
<br /> 464h-hI VR SECONDARY CONTAINMENT-Chock the material(s)used to construct the secondary containment system(s)(a g.,secondary piping)provided for the
<br /> vapor im overy piping For single-wall piping systems,check"None."Specify Other type of containment in the space provided.
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type oftransition sump(s).Chock"None"if not present
<br /> 464j-j i RISER PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e..inner)piping for all rimrs(not drop tubes)other than annular
<br /> spa"risers(i.e.,risen for filling or gauging ofthe primary tank). Specify Other type ofoontainment in the space provided.
<br /> 464k-kl RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment systcm(s)(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 /> 45la-c. FILL COMPONENTS INSTALLED-Chock the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if
<br /> applicable)arc installed.
<br /> 469a UDC CONSTRUCTION TYPE-Check the box to describe the"of dispenser containment system(s)(i.e.,dispenser sumps or pans). if the system hat m
<br /> dispensers(e.g.,standby generator tank system),check"No Dispensers." if the system has a dispenser,but no UDC,check"Nara'.
<br /> 469b. UDC CONSTRUCTION MATERIAL-Check the box to describe thematerials used to commOd the UDC.
<br /> 469c. Ifyou checked"Other"specify On construction material in ft space provided.
<br /> 448. STEEL COMPONENT PROTECTION-All systems contain some goal components. Check the appropriate boxes)to describe all corrosion protection
<br /> methods used. "Isolation"meam electrical isolation from soil,backfill,and groundwater. Examples include fiberglass cladding non-metallic secondary
<br /> containment systems which isolate steel components from the sub-surfs"environmenl,and insulating bushings.
<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 true and accurate, and that the UST system is compatible with the hazardous
<br /> substance stored.
<br /> 470. DATE-Enter the date the form was signed.
<br /> 471. APPLICANT NAME-Print or type the name ofthe person signing the form.
<br /> 472. APPLICANT TITLE-Enter the title ofthe person signing the form.
<br /> UPCF UST-B-2/2
<br /> Rev.(122007)
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