Read Microsoft Word - EIA UST Application.doc text version

ENVIRONMENTAL INSURANCE AGENCY, INC.

PO Box 23605 Portland, Oregon 97281 800-977-3335 z FAX 503-977-3334 Underground & Aboveground Storage Tank Application

Facility Name: Facility Address: Mailing Address: Business/Corporate Name: Business Phone: Type of Business: Contact Person: Current Pollution Ins. Co.: Insurance Agent: Do you own the tanks: Yes No Phone: Premium: Phone: If no, please provide the name & address of the tank owner: Business Fax: Corporation Individual Title: Renewal Date: Partnership

Are there any plans to close/remove/upgrade tanks in the next 24 months? If yes, please indicate anticipated closure/removal/upgrade date: Any leak/spill in the past 15 years: If yes, please provide details. Yes No

Yes

No

Tank Information

1 Currently in use Temporarily out of use Capacity (gallons) Contents Date installed Date lined* *Attach certification 2 3 4 5 6 7 8

Tank Construction

1 Single(sw)/double wall(dw) Steel STIP-3 Fiberglass 2 3 4 5 6 7 8

Additional Tank Protection

1 Cathodic protection Painted / Coated Fiberglass Lining Vault Pit liner 2 3 4 5 6 7 8

Tank Leak Detection System

1 Electronic

1

2

3

4

5

6

7

8

Monitoring well Dip stick monitoring Statistical Inventory

1

Attach copies of tank printouts (the printout is normally adding machine syle paper) (Attach copy of certificate) Yes No Yes No Water supply:

2

Date of last tightness test Groundwater monitoring program:

City

Well

2

Do tanks have an overfill protection system: If yes, type:

110% Containment

Yes

Concrete Pad

2

Yes

Applies to Aboveground Tanks

Piping Information

1 Date piping installed 2 3 4 5 6 7 8

Piping Construction

Single(sw)/double wall(dw) Steel Fiberglass / Flexible

Dispenser method

Suction Pressure Gravity

Piping leak detection system

Electronic Other

Additional pipe protection

Cathodic protection The applicant represents that the above statements are true and correct to the best of their knowledge and that no material or relevant facts have been suppressed or misstated and agrees that the policy, if issued will be issued on the reliance of such representations.

Applicant's Signature:

Date:

Information

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