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UST Operating Permit Application-Tank Information Instructions
<br /> (Formerly S WRCB Permit Application Form B and UPCF Form hwfvvre-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 one port of a compartmentalized unit,
<br /> each compartment is considered a separate tank and requires completion of a separate Tank Information form.For a UST permanent closure or removal,complete only
<br /> TYPE OF ACTION and Sections 1,11,111,IV,and IX.(Note: Numbering of these instructions matches the data element numbers on the form.)
<br /> 430. TYPE OF ACTION-Check the appropriate box to indicate why this form is being submitted.
<br /> 430x. 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 if installation date is known.
<br /> I. FACILITY ID NUMBER-This space is for agency use only.
<br /> 3. BUSINESS NAME-Enter the complete facility name.
<br /> 103. BUSINESS SITE ADDRESS-Enter the sheet address of the facility,including building number,if applicable. This address must be the physical location of
<br /> the facility.Pon 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#-Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the Stale tank identification
<br /> number as the unique identifier for the tank.
<br /> 433. TANK MANUFACTURER-Enter the name of the company that manufactured the wk.
<br /> 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone lank 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 jam 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: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 space provided.
<br /> 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored,
<br /> 440& 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 /> 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 wk.
<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. 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 /> 445& If you checked"Other"specify the type of secondary containment in the space provided.
<br /> 452 OVERFILL PREVENTION-Check the box(es)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 mating all
<br /> requirements of 23 CCR§2636(aX3)(also known as"European Suction'systems)(i.e.,sloped suction piping systems with no valva 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 calress tom.
<br /> 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-walled,or"other".
<br /> 464. PIPING PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)underground product(waste piping.
<br /> 464a. If you checked"Other"specify the type of primary containment in the space provided.
<br /> 4646. PIPING SECONDARY CONTAINMENT-Check the maorial(s)used to construct the secondary containment system(s)(i.e.,secondary piping,north)
<br /> provided for the productfwaste piping.For single-well piping systems,check"None."
<br /> 464c. If you checked"Other"specify the type of secondary containment in the space provided.
<br /> 464d. PIPING2URBINE CONTAINMENT SUMP TYPE-Indicate the type ofpiping/turbine containment sump(s).Check"None"if not present.
<br /> 464e-e1 VEIN PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e..inner)vent piping. (Note:Address venting of the lank primary
<br /> containment only.)Specify Other type of containment in the space provided.
<br /> 464f-ff 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 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 /> 464g-g1 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"Nona." Specify Other type of containment in the space provided.
<br /> 464h-hl VR SECONDARY CONTAINMENT-Check the materials)used to construct the secondary containment systems)(eg.,secondary piping)provided for the
<br /> vapor recovery piping For single-wal l piping systems,check"None."Specify Other type of containment in the space provided.
<br /> 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"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 risers(rot drop tuba)other than annular
<br /> space risers(i.e.,risen for filling or gauging of the primary tank). Specify Other type of containment in the spar provided.
<br /> 464k-kl RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment system(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-Check the appropriate boxes to show that spill containment tank bottom protection,and fill containment sumps(if
<br /> applicable)are installed.
<br /> 469a. 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 m
<br /> dispensers(e.g.staedbygemnator tank system),check'No Dispensers." If the system has a dispenser,but no UDC,check-None".
<br /> 469b. UDCCONSTRUCTION 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 protection
<br /> methods used. "Isolation"means electrical isolation from soil, backfill,and groundwater. Examples include fiberglass cladding,non-metallic secondary
<br /> containment systems which isolate steel components from the subsurface environment,and insulating bushings.
<br /> APPLICANT SIGNATURE-The same penon 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 /> substancestored.
<br /> 470. DATE-Enter the date the forth was signed.
<br /> 471. APPLICANT NAME-Prim or type the more of the person signing the Toon.
<br /> 472. APPLICANT TrfLE-Enter the title of the person signing the form.
<br /> UPCF USI'-B-22
<br /> Rev.(122007)
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