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CO Dept of Labor & Employment – Division of Oil & Public Safety

633 17th Street, Suite 500, DenverCO80202-3660
Phone 303-318-8505/8507 – Fax 303-318-8518 – E-mail – Web

UNDERGROUND STORAGE TANK SYSTEM INSTALLATION AND UPGRADE APPLICATION

Facility Name: / Owner Name:
Address: / Address:
City: / State: / CO / Zip: / City: / State: / Zip:
Contact
Name: / Phone #: / Contact
Name: / Phone #:
Description Of Work:
Type Of Facility: Gas Station [ ] Bulk Plant [ ] Commercial/Industrial [ ] Airport [ ] Government [ ] Other [ ]
A plot plan must accompany this application that includes the name and address of facility, lot dimensions, and distances from tanks to nearest important building, roads, railroads, property lines, dikes or impoundment areas, existing tanks, and dispensers.
TANK INFORMATION / Tank Material Codes
New or Existing Tank / ST: Cathodically Protected Steel
Tank Material (Construction) / FRP: Fiberglass Reinforced Plastic
Tank Wall Type / COMP: FRP/Steel Composite Tank
Total Capacity (gals) / JKT: Jacketed Steel Tank
Compartmentalized Tank (Y/N) / Tank/Piping Wall Type Codes
Compartment Sizes / S: Single Wall D: Double Wall
Product (by compartment if app) / Anchorage Method Codes
Tank Manufacturer / HP: Hold-down Pad (Concrete Slab)
Tank Model (Envirovault, etc.) / DM: Deadmen NONE: Overburden Only
Serial # / Overfill Prevention Method Codes
Manifolded Tank (Y/N) / BF: Ball Float Valve FV: Fill Tube Valve
Anchorage Method / AL: External Audible/Visible Alarm
Spill Containment Manufacturer / Tank Corrosion Protection Codes
Spill Containment Size (in gals) / FRP: Fiberglass Reinforced Plastic
Overfill Prevention Method / COMP: FRP/Steel Composite Tank
Overfill Prevention Manufacturer / JKT: Jacketed Steel Tank
Tank Corrosion Protection / IC: Impressed Current System
Vapor Recovery Reqd (Y/N) / GV: Galvanic Anodes LN: Internally Lined
Vapor Recovery System Piping: Line Size: [ “ ] Connection Size [ “ ] / LN+: Internally Lined + Cathodic Protection
Tank Release Detection Mthd. / Tank Release Detection Method Codes
PIPING INFORMATION / T1: ATG .2/.1 gph Monthly Monitoring
New or Existing Piping / T2: Interstitial Monitoring w/ Sensor
Piping Type / T3: Interstitial Monitoring w/out Sensor
Piping System / T4: SIR (Statistical Inventory Reconciliation)
Piping Material / T5: Inventory Reconciliation + Precision Testing
Piping Wall Type / Piping Type
UG Piping Manufacturer / AG: Aboveground UG: Underground NA: None
Model (Pisces, Red Thread, etc.) / Piping System Codes
ALLD Type (UG piping) / PR: Pressurized
UG Piping Connector-Tank / SU: Suction SS: Safe Suction
UG Piping Connector-Disp / GRAV: Gravity Feed NONE: No Delivery Piping
Piping Corrosion Protection / MAN: Manifolded Tank – No Delivery Piping
Connector-Tank Corr. Protection / Piping Material Codes
Connector-Disp Corr. Protection / FRP: Fiberglass Reinforced Plastic
Sec. Contmnt.- TK/STP (Y/N) / FLEX: Flexible Plastic Piping
Sec. Contmnt.- Disp (Y/N/NA) / STEEL COPPER
Piping Release Detection Mthd. / Line Leak Detector (ALLD) Type Codes
ADDITIONAL INFORMATION / E: Electronic M: Mechanical
ATG Manufacturer/Model / NA: Not Required - (Manifolded/Gravity, etc.)
Tank Pit Monitoring Wells (Y/N): [ ] Number: [ ] Location: / Piping Connector Type Codes
Excavation Liner (Y/N) / SW: Swing Joint FL: Flex Conn FPP: Adaptor

UNDERGROUND TANK INSTALLATION INFORMATION

/ Piping Corrosion Protection Codes
Backfill Material (squeege, crushed rock, sand, etc.): Type: [ ] Depth: [ “ ] / FRP: Fiberglass Reinforced Plastic (Piping)
Bedding Depth: [ “ ] (12” minimum unless hold-down pad is used) / FLEX: Flexible Plastic AG: Aboveground Piping
Cover (concrete, asphalt, backfill only, etc.): Type: [ ] Thickness: [ “ ] / IC: Impressed Current System (Piping/Connectors)
Will excavation cover be subject to traffic? Yes [ ] No [ ] / GV: Galvanic Anodes (Piping/Connectors)

BURIED PIPING INSTALLATION INFORMATION

/ NC: No Electrolyte Contact (Connectors)
Backfill Material (squeege, crushed rock, sand, etc.): Type: [ ] Depth: [ “ ] / BT: Plastic Boot (Connectors)
Cover (concrete, asphalt, backfill only, etc.): Type: [ ] Thickness: [ “ ] / Piping Release Detection Method Codes
INSTALLER INFORMATION / L1: ATG .2/.1 gph Monthly Monitoring
Installer name (company): / L2: Double-wall & Sumps w/ Sensor
L4: SIR (Statistical Inventory Reconciliation)
L5: Annual Line Tightness Testing
L7: Not Required (SS/GRAV) L8: 3yr LTT
Installer address:
Installer City/State/Zip: Phone #:
FEE FOR UST SYSTEM PLAN REVIEW AND INSTALLATION INSPECTION IS $150.00 PER FACILITY
Please pay by check or money order payable to Division of Oil & Public Safety
OPS USE: Check # ______Check Amount $ ______Date Received ____/____/____
Date Reviewed / _____/_____/_____ / Approved By / ______ / OFL / OUP / ______

10/04