Aboveground Storage Tank (AST) Program
Doc Type: Permit Application
To comply with pollution prevention goals and to save file space; please use double sided copies and do not use plastic covers, inserts, or binders on all applications or submittals.
State the permit modification requested and reference tank numbers affected by the request:State the reason for the permit modification request:
Instructions
- Not all actions related to aboveground storage tanks (AST) require a permit modification. For further information, review your permit or consult with the AST major facility permit staff.
- Answer questions using information that is currently available. Where an answer to a question is unknown, or would require further testing or assessment, indicate “Unknown”.
- Requested information may be found in your company’s initial AST permit application.
- Make sure the application form is signed by the appropriate authorized company representative.
- For the application to be considered “Substantially Complete”, submit: 1) signed application form; 2) answers to questions; and 3) all required attachments to:
Permit Document Coordinator
Minnesota Pollution Control Agency
520 Lafayette Road North
St. Paul, MN 55155
I.Current AST Permit
AST permit number: / Date issued (most recent revision):Permit expiration date: / Company contact name:
Contact phone number: / Contact e-mail address:
II.Facility Owner/Operator
Corporate name:Mailing address:
City: / State: / Zip code:
Registered agent name: / Phone number:
Status of Owner/Operator: Federal State Public Private Other (explain):
III.Location of Facility
Street or highway address:City or township: / County:
Legal description:
AST site registration numbers:
IV.Description of Business Activities
Check box if business activities have expanded or otherwise been modified from the date indicated in Part I.2. If box is checked, briefly describe the nature of current business or activities at the facility and how aboveground liquid storage is used in the course of the business or activities in an attachment.
V.Environmental Impact Statement
Check box if a new or amended:
1.Environmental Impact Statement under the National Environmental Policy Act; or
2.Environmental Assessment Environmental Statement prepared under rules of the Minnesota Environmental Quality Board, Minnesota Rules, chapters 4400 and 4410 has been prepared since the date indicated in Part I.2. If box is checked, please submit the latest draft or final of such statements.
VI.Permit Modification Requested
Company name change or change of ownership
For the tank(s) affected by the requested permit modification, please (a) check the box next to each item that has changed to date, will change as a result of the modification, or was mistakenly reported in prior applications; and (b) describe all changes for the checked items in an attachment.
Note: For approval to construct either a new field-erected tank or a new underground piping segment, check here
and complete Attachment 1, “New Field-Erected Tank and Underground Piping Construction,” in lieu of Part VI.
A.For outdoor tanks affected by permit modification
Tank number. Use tank numbering system established in current AST permit.
Substance. Identify the product or type of product designated in the current permit if different from currently stored substance and the desired change.
Design capacity (in gallons).
Year of installation.
Status. Active (currently or intermittently contains liquid substance) or Closed (currently empty and resumption of storage is not anticipated).
Tank material. Steel, Fiberglass, Plastic, or Other (describe).
Fabrication. Shop-fabricated or Field-erected.
Tank wall. Single or Double.
Tank floor. Single, Double, or Coated (identify material).
Tank base (area under floor). Ringwall, Slab, Liner (describe), Sand, Native Soil, Other or Combination (describe).Note if tank is Elevated.
Liquid level gauging. Manual, Float, Electronic, None or Other (describe).
Overfill protection system.
Corrosion protection system for underside of tank floor.
Leak detection system.
Date of most recent out-of-service inspection and method used. (Note: Copies of inspection reports may be requested after application is submitted.)
Scheduled or estimated date of next out-of-service inspection.
B.For indoor tanks affected by permit modification
An indoor tank is one which is located inside of a building on or above an impermeable floor, from which a spill in the amount of the design capacity of the tank:
1.would be entirely contained within a tank-specific secondary containment structure
2.would not reasonably be expected to escape from the building through doorways, floor drains, or by other means
3.would be directed by the drainage system of the building either to a permitted on-site wastewater treatment facility or to a permitted municipal wastewater treatment facility
Tank number
Substance
Design capacity (in gallons)
Indoor containment method (identify by indicating a, b, or c)
C.Secondary containment
Containment area number keyed to facility map
Tank number of each tank within area
Volume
Construction materials
Permeability (only if native soil and amended clay liners)
D.Other factors
Check box if any other information contained in your company’s previous permit or permit modification application that is necessary to evaluate the current permit modification request has changed. If box is checked, state the nature of the inaccuracy or change in an attachment.
VII.Site Geology
Check appropriate box if site geology information given on the date indicated in Part I.2. has been determined to be inaccurate or changed in any other way. If box is checked, state the nature of the inaccuracy or change in an attachment.
Average or estimated depth to groundwater (in feet).
Native soil classification, between surface and groundwater.
Calculated or estimated vertical permeability or native soil (cm/sec), not including any containment liner.
Average or estimated depth to bedrock (in feet).
Bedrock type and formation name, if known.
Describe any existing tank- or pipe-related site contamination, or any investigation indicating no contamination.
VIII.Attachments
- Any explanation required for Parts I through VII.
- Revised facility map if different from facility map currently submitted to MPCA.
VIII.Certification
Certification must be signed by an authorized company representative who is a member of company management.
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
Signature: / Date:Print name: / Title:
Mailing address:
City: / State: / Zip code:
Telephone number:
Attachment 1
New Field-Erected Tank and Underground Piping Construction
Note: For underground piping segment only, complete sections 1, 2, 4, 5, and 19-22 only.
1.Tank number (If piping only, list tank or tanks to which piping is appurtenant)
2.Substance (Identify the substance with as much specificity as possible. For petroleum products, food products, and chemicals, identify grade, type, or solutions. If different substances at different times, list all. If the substance is a mixture, a solution, or has identifiable contaminants, list all components of the substance, with percentages. If other substances are anticipated in the future, list these.)
3.Capacity(Design capacity to overflow, in gallons)
4.Materials/type (Steel single wall, stainless steel single wall, steel double wall, concrete, or plastic. If other, describe.)
5.Construction standards(API 650 or other standards)
6.Tank roof type(Fixed, internal floating, external floating, etc.)
7.Tank foundation and floor design (Provide engineering detail drawings of tank floor and foundation. Specify whether tank will rest on continuous concrete slab or pad [specify whether concrete will be coated], or tank will have an under floor release prevention barrier with interstitial monitoring [specify synthetic material to be used and thickness in mils, and whether design includes concrete ring wall].)
8.Internal tank floor coating or liner (If any, specify whether coating or liner will be designed and installed according to API 652; base material [epoxy, HDPE, etc.]; thin coat [less than or equal to 20 mils] or thick coat [greater than 20 mils]; and whether liner is fiberglass reinforced.)
9.Cathodic protection system for underside of tank floor (If any, specify whether system will be designed and operated according to API RP 651; and whether system is sacrificial anode or impressed current type.)
10.Substance transfer methods – In(Identify all methods by which substances may be transferred into the tank, e.g. from tank truck, from rail car, from barge, or by fixed piping from industrial process, from other tanks, or from outside the facility.)
11.Substance transfer methods – Out(Identify all methods by which substances may be transferred out of the tank, e.g. to tank truck, to rail car, to barge, to aircraft, or by fixed piping to industrial process, to other tanks, or off the facility property.)
12.Substance transfer safeguards (For each substance transfer method, describe containment area at transfer vehicle connection point, including materials of construction and maximum spill volume contained. Provide engineering detail drawings. Show location of each transfer area on facility map.)
13.Remote transfers(Describe whether remote transfers may occur, during which transfers either in or out are initiated, monitored, terminated, or otherwise controlled from outside of the facility, e.g. interstate pipelines; and identify if remote transfers may occur when the facility is unmanned.)
14.Overfill prevention system (If any, specify whether system will be designed and operated in accordance with API 2610; and whether the system is most closely described by one of the overfill prevention levels 1, 2 or 3 defined below.)
- Level 1 = High level alarm visible or audible to person controlling the fill, API RP 2350 design. Level set at no greater than 95% of capacity to overfill and no less than 30 minutes to overfill at maximum fill rate. Alarm need not be independent of gauging system. Applicability: Attended transfers of Type A and Type B substances from vehicle (truck, railcar, barge) into tank containment, and Type C1 substances
- Level 2 = Level 1, plus alarm is fully independent of tank gauging system. Applicability: Unattended transfers (individually initiated and terminated by personnel) of Type A and Type B substances from industrial process, from other tanks, or from off-site pipeline into tank
- Level 3 = Level 2 plus automatic shutoff device fully independent of tank gauging system. Applicability: Automated and/or continuous transfers (not individually initiated and terminated by personnel) of Type A substances from industrial process into tank; or unattended transfers (individually initiated and terminated by personnel) of Type A and Type B substances from industrial process, from other tanks, or from off-site pipeline into tank
- Other, please describe
15.Tank secondary containment – Available volume (Estimated net available volume of containment in gallons, accounting for contour of land, slope of dike walls, piping, tanks, buildings, and other obstructions within area. Note: For earthen diking, a post-construction survey is required.)
16.Tank secondary containment – Construction materials(Identify primary materials used for containment area construction, for example synthetic liner [identify material], concrete block, poured concrete, coated concrete, steel, native soil, engineered clay liner [provide permeability specification expressed as hydraulic conductivity to water in cm/sec], or geotextile--bentonite mat. If dike walls and basin floor are different, describe each. Attach construction specifications and drawings.)
17.Aboveground piping(Aboveground piping includes piping not in contact with the ground. For any such piping, describe generally. Show locations on tank drawings.)
18.Short-run underground piping(Short-run underground piping includes dike penetrations, roadbed crossings, and other line segments that are less than 50 feet in length. For any such piping, describe fabrication [steel, plastic, other] and any release prevention, detection or containment features, such as coatings, wrappings, double-walled piping, cathodic protection, sleeving, or trenching. Show locations on tank drawings.)
19.Long-run underground piping(Long-run underground piping includes any line segments that are more than 50 feet in length. For each segment, give the segment name or number, endpoints, diameter, fabrication [steel, plastic, other], and any release prevention, detection or containment features such as coatings, wrappings, double-walled piping, cathodic protection, sleeving, or trenching. Show locations on tank drawings.)
20.Estimated construction start date:
21.Estimated initial fill date:
22.Facility map(On a facility-wide map, identify location of proposed new tank(s), and any associated containment areas, transfer areas, aboveground piping segments, and underground piping segments.)
651-282-5332 or 800-657-3864•Available in alternative formats
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