Fillable Tank System On-Site Cleaning Application Form printable pdf download

TANK SYSTEM ON-SITE CLEANING APPLICATION

For use by Unidocs Member Agencies or where approved by your Local Jurisdiction

Authority Cited: California Code of Regulations, Title 22, Section 67383.3(a)(1)

This application form, and a Tank System Closure Permit Application, must be completed and submitted to the

local Unified Program Agency (UPA) prior to on-site cleaning to render non-hazardous any aboveground or

underground storage tank system that previously stored a hazardous material/waste.

1. Facility Name (Tank Site):

Bldg. No.:

Address:

City:

Zip:

2. Proposed Date of Tank System Cleaning:

3. The following individual will directly supervise cutting and/or cleaning activities and prepare the Hazardous Waste Tank Closure

Certification form:

Name:

Phone No.:

(

)

Address:

City:

Zip:

Submit a copy of this person’s “statement of qualifications” including experience and professional credentials (e.g., state

license or registration) demonstrating that he/she is technically and legally qualified to certify tank cleaning activities.

4. The following procedures will be used for the on-site cleaning and closure of these tank systems: [Describe the specific tools and

techniques proposed for cleaning, cutting (if applicable), and visual inspection of tank interior(s)] Attach copies of your site-

specific Work Plan and site-specific Safety Plan with this completed permit application.

5. Where will rinseate be shipped?

Facility Name:

EPA ID No.:

Name of Transporter:

EPA ID No.:

6. Do the tank(s) have manways?

Yes;

No. If No, describe in your attached Work Plan how you will access the tank

interior(s) to perform the required visual inspection of the entire tank interior [i.e., describe the specific methods will be used to

cut openings in the tank(s) large enough to facilitate the required visual inspection, or what remote viewing equipment/methods

will be used). [If openings must be cut, Fire Department approval is required prior to cutting.]

Fire Department Tank Cutting Approval

If tank closure is being overseen by Santa Clara County CUPA and the tank(s) will be cut, this section must be

submitted to, and completed by, the local Fire Department prior to submittal of this application to the CUPA.

This Department has reviewed the proposed non-sparking tank cutting methods and/or remote viewing equipment and

lighting systems described in Section 4, above, and approves their use.

______________________________________________ _______________________________________ ____________________

Fire Department Representative Name (Print)

Fire Department Representative Signature

Date

Agency:

Santa Clara County FD;

San Jose FD;

Morgan Hill FD;

Palo Alto FD;

Cal/Fire;

Moffett Field FD

Comments/Conditions: ________________________________________________________________________________________

UN-066

1/2 – Rev. 12/16/15

Tank System On-Site Cleaning Application Form

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