Permit Application #2006.2 Mobile Fueling– Site

Submit Paper Work by Hand, Mail, Fax, E-mail to:
To be completed by the Permit Applicant (type in the grey box or print out and complete)

Business Information

Date:
Business Name:
Address: / Street / City / State / Zip
Site Address: / (if different from above)
Contact Name:
Phone: / () / Alternate Phone/Cell: ( )
E-mail Address:
City of TacomaBusiness License:
Mobile fueling service to be provided by:
Comments:

Please include a check made payable to the CITY OF TACOMA TREASURER, or request an invoice.

Check this box to have applicant invoiced for this permit.

FPB OFFICIAL USE ONLY

Approved By: / Date:
Denied: / Reason for Denial:
Comments:
Permit Number:
Permit Fees: / Date Received: / Receipt Number: / Check Number:

See attached documentation for description of conditions that must be met prior to the issuance of this permit.

- Mobile Fueling -

PERMIT CONDITIONS: #2006.2 - Mobile Fueling - Site

All of the following conditions must be met prior to the issuance of a permit.

1. Time Lines

a. An annual permit shall be issued to the Mobile Fueling vendor and the site prior to
commencement of any fuel delivery.

2. Regulatory References

a. Tacoma Municipal Code 3.10

b. International Fire Code 34

c. 49 CFR 178

3. Required Submittals

  1. Tacoma Fire Department (TFD) Site Permit Application.

b. Documents required on each application.

c. City of Tacoma business license.

d. CompanySpill Response Plan

4. Inspection Requirements

a. Tanker trucks are required to be inspected and approved prior to permit being
issued.

b. Sites receiving fuel shall be inspected and approved prior to permit being issued.

5 Requirements

a. Meet requirements stated on applications.

MOBILE FUELING SITEPERMIT APPLICATION FORM

12 month Application Period _____-_____ to _____-_____

(mo) (yr) (mo) (yr)

I have attached a site plan showing all important buildings, facilities, hazardous materials, parking, lighting, fencing, openings into buildings, storm drains, hydrants and proposed location of fueling.

The area where fueling is proposed to occur on:

Continuous pavement (asphalt or concrete).

Dirt or gravel.

A combination of pavement and dirt/gravel.

Other, please specify ______.

I have/am in process/ or will notified all persons with an interest in the property regarding our intentions of mobile fueling and the extent of insurance coverage carried.

Check all the boxes that apply:

Fueling is to be done between ____a.m. and ____ p.m. on: Mon / Tue / Wed / Thurs / Fri / Sat / Sun

The area where fueling is to take place has general yard lighting.

Security and restricting public access is a problem at this site.

We are located in South Tacoma Ground Water District. Indicate the PCDH permit number and permit date:

I understand that no fueling may occur until a permit has been issued.

I have received a copy of the Mobile Fueling requirements for the City of Tacoma and understand those which apply to sites.

I understand that it is my responsibility to inform all persons and parties with property interest that mobile fueling will be occurring on this site and of the risk and the extent of insurance coverage provided by the fueling company.

I understand that Mobile Fueling without a Permit is a violation and citations will be issued to both the site manager/owner and the tanker operator/owner. A Mobile Fuel Company Permit may be revoked for fueling at an un-permitted site.

I understand that with a Mobile Fueling Site Permit that only companies holding a valid City of Tacoma Mobile Fueling Company Permit may fuel on the site and that the City of Tacoma, Fire Prevention Bureau (591-5740) shall be notified prior to any change in fueling companies.

I understand that the City of Tacoma, Fire Prevention Bureau (591-5740) shall be notified whenever site alterations are made which affect locations of fueling.

I understand that Permits are not transferable between parties or companies.

I understand that violation of each and any of the rules/laws regulating Mobile Fueling constitutes a separate criminal misdemeanor offense. Each offense is subject to penalties from $100 to $1,000. Each offense can also be compounded daily.

I, as owner or operating manager of the facility named here in, here-by declare that all the information contained in this document is correct and true. I also understand that false statement(s) or misrepresentation as to a material fact in this application constitutes grounds for revocation of any permit.

SignatureDate

______

Printed name of person signingTitle of person signing

------
______FPB Employee Initials □ Fee has been received.

MOBILE FUELING

SITE INSPECTION CHECKLIST

Business Name: ______Address: ______

Company Representative: ______Phone:______

Fueling Site: ______Fueling Days______

Number of Vehicles to be Fueled: ______Fueling Hours______

1.II / If Site is outside the South Tacoma Groundwater Protection District (refer to map)
Site surface - asphalt or concrete continuous, sealed and in good repair
Exception: Not required if tankers are equipped with auto start/stop nozzle and
operator carries a remote shutoff.
2. / If Site is inside the South Tacoma Groundwater Protection District (refer to map)
Site surface SHALL be protected by continuous asphalt or concrete in good repair
3. / Fueling site requirements:
a) Site is at least 15’ from all buildings, combustible storage, compressed gas tanks, and
Class I, II, or III storage tanks.
Exceptions: 1) Tanks are approved 2 hour protected assemblies
2) Building(s) is/are covered parking with non-combustible roof and open
on all sides, fueling operations can occur within the structure
b) Site is 25’ from building openings, storm drains or combustible materials
Exceptions: 1) Tanker has approved drain cover in place or
2) Storm drains direct intake to approved oil/water separator
c) Site is 25’ from property lines and public ways and distinguishably sloped away
d) Distance reduced by permit if a barrier is present to prevent liquid flow off-site
4. / Yard lighting on-site capable of providing 1.0 ft. candle
a) Tanker must have flood lighting otherwise fueling operations are restricted to daylight hours
5. / Site has designated fueling location marked by blue lines or an approved and conspicuously
posted site map
6. / Site is secure from general public access fences or other barriers must be in place
8. / Mobile fueling site shall not be within a 50’ radius of any designated wetland as measured
from the outer edge of the buffer boundary of the designated wetland or the high water maker
of a body of water when no boundary exists.
Exceptions: 1) Approval of the City designated Environmental Program Coordinator
2) All sites adjacent to wetlands shall have on site 50’ of 4” diameter
containment boom
9. / Mobile fueling shall not be permitted where unusual hazards to life and property exist
PERMIT CONDTIONS
Use of tankers that provide general yard lighting.
Use of tankers with auto start/stop nozzles and remote emergency shut-off
50’ of 4” non-water absorbent boom
Marked fueling locations or a conspicuously posted site map with approved fueling locations / Drain cover/s.
Day time fueling only
Continuous pavement in good repair
Public access barriers
4” curbs or other approved barriers to prevent flow off site.

Approved Denied Reason for denial ______
Inspector______Date______