Petroleum Storage Program

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1 Petroleum Storage Program Renewal Application Form: Permit to Operate Petroleum Storage Facility UNDERGROUND STORAGE TANK SYSTEM IMPORTANT Renewal applications can take up to 0 days to process. Late applications may result in not receiving a permit to operate before your current permit expires. All applications will be reviewed in the order they are received. Incomplete applications will be returned, unprocessed, to the applicant. Completed applications and all associated documents must be submitted to: OR Manitoba Conservation and Water Stewardship Petroleum Storage Program Environmental Approvals 00 Century Street Winnipeg MB RH 0W For additional information, please visit: PSF_APP_00 0_Underground

2 For Internal Use Only Date Received: EMS OP ID: Application Complete: Yes No Approval ID: File No.: Office: Storage Tank System Owner Information Legal name: (Corporation or individual s name) Mailing address: City: Province: Postal code: (Town or village) Contact person: Title: Telephone: Fax: Tank System Operation Information Operation name: Permit number: Operation owner: (Corporation or individual s name) Tank location: (Legal land description [e.g.: civic address; section-township-range; GPS]) Municipality: Mailing address: City: (Town or village) Contact person: Postal code: Title: Telephone:

3 Underground Storage Tank System Information Storage Tank Information Tank ID No. (as per attached site plan) Nominal Tank Capacity (in litres) Split Tank (vol/vol in litres) Product(s) Stored Serial No. Tank Manufacturer Year of Installation Double walled (D) or single walled in secondary containment (S) In-Service Monitoring as Required by the CCME Code of Practice, Part /Technical Bulletin PSF-00 () Statistical Inventory Reconciliation () Inventory Reconciliation () Visual Leak Detection () Automatic Tank Gauge () High Technology Secondary Containment Monitoring () Continuous In-tank Leak Detection System () Continuous In-Tank Leak Detection () Observation Well Monitoring () Electronic Line Leak Detection Device (0) Sensor () Single Vertical Check Valve 0 Are you conducting the in-service monitoring at the frequency required by the CCME Code of Practice? Yes No Periodic Leak Detection as Required by the CCME Code of Practice, Part /Technical Bulletin PSF-00 () Precision Leak Detection Test () Pressure Liquid Media Leak Detection Test () High-pressure Inert Gas or Vacuum Leak Detection Test () Visual Leak Detection Page of

4 Annual Inspection and Performance Testing as Required by the CCME Code of Practice, Section..()/Technical Bulletin PSF-00 () Automatic Tank Gauges and Monitoring Systems () High-technology Sensors () Electronic or Mechanical Leak Detection Equipment () Corrosion Protection Equipment () Pressurized Piping Emergency Valves () Emergency Shut-down Devices Name of Service Provide: () Containment Sumps Including Dispenser, Turbine and Transition Containment Devices () Overfill Protection Devices Page of

5 Certification I,, certify that the information contained on this Print name form is complete and accurate, and understand that untrue or misrepresented information may result in this application being denied. Signature of facility owner Date Return completed application form to: Manitoba Conservation and Water Stewardship Petroleum Storage Program Environmental Approvals 00 Century Street Winnipeg MB RH 0W Personal information is collected under the authority of The Dangerous Good Handling and Transportation Act, the Storage and Handling of Petroleum Products and Allied Products Regulation and is used to issue permits and for enforcement purposes. Information collected is protected by the privacy provisions of The Freedom of Information and Protection of Privacy Act. If you have any questions, contact the Access & Privacy Coordinator, Box, 00 Salteaux Crescent, Winnipeg MB RJ W; Page of