Aboveground Petroleum Storage Act (APSA) 92415 Tank Facility


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San Bernardino Co. CUPA 620 South “E” Street San Bernardino, CA 92415 Tel: (909) 386-8401 Fax: (909) 386-8460 www.sbcfire.org

Aboveground Petroleum Storage Act (APSA) Tank Facility Statement
Notification/Change in Status

I. Facility/Business Information

Facility CUPA ID# 1

Facility Name

3

FA

Facility Address

103

City Contact Name

104
CA

Zip Code 105

117 Contact Phone

118

II. Total Facility Capacity in gallons

921

Facility’s total aboveground petroleum product storage tank capacity for all tanks/containers/equipment/systems TOTAL CAPACITY

greater than or equal to 55 gallons (see directions on reverse)

gal

III. Tank Details – Include each aboveground petroleum storage tank that exceeds 10,000 gallons in storage capacity.

Attach additional pages should your facility have more tanks.

Tank ID #
(e.g. 1, 2, 3, etc.)

Contents
(Gas, Diesel, etc.)

Capacity
(In gallons)

Tank Location
(Describe location or attach site map or plot plan)

IV. Signature

I certify under penalty of law that the information submitted is accurate and complete to the best of my knowledge.

Signature of owner or tank facility operator

134 Print name of owner or tank facility operator

135 Date (mm/dd/yyyy)

136

Revised 06/23/2016 YS

Page of

Aboveground Petroleum Storage Tank Facility Statement

I. FACILITY/ BUSINESS INFORMATION: 1. FACILITY CUPA ID NUMBER – This number is found on your CUPA permit. 3. FACILITY NAME –Enter the name of the business, facility or DBA for this site. 103. FACILITY ADDRESS – Enter the street address where the aboveground storage tank facility is located. No post office
box numbers are allowed. This information must provide a means to geographically locate the facility. 104. CITY – Enter the city or unincorporated area in which the aboveground storage tank facility is located. 105. ZIP CODE –Enter the zip code of aboveground storage tank facility. The extra 4 digit zip may also be added. 117. CONTACT NAME – Enter the name of the person who receives Aboveground Petroleum Storage Tank correspondence. 118. CONTACT PHONE – Enter the phone number, area code first, and any extension.

II. TOTAL FACILITY ABOVEGROUND PETROLEUM STORAGE CAPACITY: 921: TOTAL FACILITY CAPACITY- Enter the facility’s total aboveground storage tank capacity (in gallons) of petroleum. Petroleum is defined under APSA as crude oil, or a fraction thereof, which is liquid at 60 degrees Fahrenheit and 14.7 pounds per square inch absolute pressure. Petroleum includes waste oil and other waste petroleum products. It does NOT include antifreeze, propane, or natural gas. There is no exemption based on the percentage of petroleum. Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum and that is substantially or totally above the surface of the ground, including a tank in an underground area. To calculate the capacity of 55 gallon drums on site, use the maximum number of drums that would typically be stored at your facility. Total gallons may be tabulated individually or cumulatively; the total capacity could be derived from just one aboveground tank, several aboveground tanks, 55-gallon drums, or both tanks and drums. For example, a facility may have petroleum stored only in 55-gallon drums, but if there are 24 drums, then the total capacity is 1,320 gallons and the facility would qualify as a tank facility. Or a facility may have three 240-gallon aboveground tanks containing petroleum products and eleven 55-gallon drums of petroleum products and still qualify as a tank facility. Enter the total capacity and not the amount actually stored. The entire 2,000 gallons of an aboveground storage tank with a capacity of 2,000 gallons would be counted even if the tank never actually contained more than 1,000 gallons.

Worksheet to Calculate Total Petroleum Capacity for your Facility: a + b + c = Total Facility Capacity*

No. of tanks x size = Total Capacity in gallons (e.g., 2 x 550 gal AST = 1100; 6 x 55 gal. drums = 330; 1100 + 330 = 1430 gals.)

________ x 55 gal. = _____________

_______ x 1,000 gal. = ______________

_______ x _______ gal. = ______________

________ x 100 gal. = _____________

_______ x 2,000 gal. = ______________

_______ x _______ gal. = ______________

________ x 250 gal. = _____________

_______ x _______ gal. = ______________ _______ x _______ gal. = ______________

________ x 500 gal. = _____________

_______ x _______ gal. = ______________ _______ x _______ gal. = ______________

Subtotal (a) = _____________

Subtotal (b) = ______________

Subtotal (c) = ______________

*NOTE: When determining whether a facility meets the criteria as a qualified facility, the total aboveground storage capacity

of all non-petroleum oils (such as animal, vegetable, or synthetic oils) must be combined with the total aboveground

petroleum storage capacity in order to determine whether the facility exceeds the 10,000-gallon qualified facility limit.

III: TANK DETAILS: TANK ID# – Enter a tank identification number if applicable. You may create your own numbering system. CONTENTS – Enter the contents (e.g., GASOLINE, DIESEL, WASTE OIL) of the aboveground storage tank. CAPACITY – Enter the aboveground storage tank’s capacity (Shell capacity in gallons). TANK LOCATION – Enter general location of the tank at your facility (e.g., at north end of facility; inside maintenance shop)
or attach a site map or plot plan that shows tank locations.

IV. SIGNATURE: 134. SIGNATURE OF TANK FACILITY OWNER OR OPERATOR- The form must be signed, in the space provided, by the
owner or operator. 135. PRINT NAME OF TANK FACILITY OWNER OR OPERATOR- Print or type the full name of the person signing the
form. 136. DATE – Enter the date (mm/dd/yyyy) the form was signed.

Revised 06/23/2016 YS

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Aboveground Petroleum Storage Act (APSA) 92415 Tank Facility