Fillable Printable Underground Storage Tank Addendum
Fillable Printable Underground Storage Tank Addendum
Underground Storage Tank Addendum
For assistance or to request this document in an alternate format, visit //business.wa.gov/BLS or call 1-800-451-7985.Teletype (TTY) users may use the Washington Relay
Service by calling 711.
BLS-700-041 (6/2/14) PAGE 1 OF 4
State of Washington
Business Licensing Service
PO Box 9034
Olympia, WA 98507-9034
1-800-451-7985
Underground Storage Tank Addendum
(For new tanks and change in ownership)
This form must accompany a Business License Application.Keep a copy of the completed form and the instruction
sheet for future reference.
Tank site informationSee pages 1 and 2 of the instructions for proper codes.
UBI number
Owner name
I
Ecology Use Only
Site # Region
FS # County
1.
Site Location
PRINT or TYPE Site nameOn-site telephone number
PRINT or TYPE Physical location of site
City, State, Zip codeCounty
2a.
Tank Owner Information (if different than business owner)
NameTelephone number
Mailing address
City, State, Zip code
2b.
Tank Operator Information (if different than tank owner)
NameTelephone number
Mailing address
City, State, Zip code
2c.
On-site Contact Person
NameTelephone number
Mailing address
City, State, Zip code
( )
( )
( )
( )
Reset This Form
Print This Form
For assistance or to request this document in an alternate format, visit //business.wa.gov/BLS or call 1-800-451-7985.Teletype (TTY) users may use the Washington Relay
Service by calling 711.
BLS-700-041 (6/2/14) PAGE 2 OF 4
III
II
I
Tank site information(cont.)
3.Ecology UST ID (if known)
..................................................
4.This application is for:
A change of ownership of an existing site
(complete sections I, II & VI)
A new facility with underground storage tanks (complete all sections)
A new tank installation at existing site (complete all sections)
5.Tank site use type (NAICS Code)
...........................................
6.Number of dispensers at the facility
......................................................
7.Number of dispensers at facility with under dispenser containment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.If you would like a technical assistance inspection, please check this box
...........................
Financial responsibility information See Pages 1 and 2 for the instructions for Proper Codes
1.Financial responsibility limits category
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.Method of compliance with financial responsibility requirement
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.Attach the appropriate proof of financial responsibility as described in the instructions.
4.Retroactive date
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/ /
Site plan (FOR NEW TANKS ONLY)
An as-built site plan of the tank and piping installation has been attached. (Include all information
requested in the instructions.)
The installation supervisor has signed the last page.
The Manufacturer's Installation Checklist has been sent to:
Department of Ecology
Underground Storage Tanks
PO Box 47600
Olympia WA 98504-7600
* Always contact local authorities regarding permit requirements.
For new or unregistered tanks only
UBI number
IV
Individual tank information See pages 2 and 3 of the instructions for proper codes before completing this section.
First TankSecond TankThird TankFourth TankFifth Tank
A Tank name
B Installation date
C Tank status
D Tank material
E1 Tank construction
E2 Manifolded tank
F Tank release detection
G Tank tightness testing
H Tank corrosion protection
I Spill protection
J Overfill protection
K Piping material
L Piping construction
M1 Piping release detection
(primary)
M2 Piping release detection
(secondary) (if applicable)
O1 Piping corrosion protection
O2 Steel flex connector at tank
O3 Steel flex connector at
dispenser/pump
P Pumping system
Compartments123123123123123
Q Substance stored
R Substance use
S Compartment capacity
For assistance or to request this document in an alternate format, visit //business.wa.gov/BLS or call 1-800-451-7985.Teletype (TTY) users may use the Washington Relay Service by calling 711.
BLS-700-041 (6/2/14) PAGE 3 OF 4
For assistance or to request this document in an alternate format, visit //business.wa.gov/BLS or call 1-800-451-7985.Teletype (TTY) users may use the Washington Relay
Service by calling 711.
BLS-700-041 (6/2/14) PAGE 4 OF 4
Installer certification
I hereby certify that the installation of the new underground tank system listed on this form was completed according to
all applicable regulations, codes and standards and that a certified supervisor was on site during all required installation
activities.
_________________________________________________________________ __________________________________________________________________
Print company name Certified supervisor name
_________________________________________________________________ __________________________________________________________________
Certification number (Area code) Telephone number
_______________________________________________________________________________________________________________________________________
Address
_______________________________________________________________________________________________________________________________________
City, State, ZIP code
_________________________________________________________________ __________________________________________________________________
Email address Signature of certified supervisor Date
Owner/operator agreement to terms and conditions of UST compliance tag
Owners and operators of petroleum underground storage tanks (USTs) must:
•maintain proof of financial responsibility for taking corrective action and compensating third parties for bodily injury
and property damages caused by petroleum releases.
•provide release detection for petroleum USTs that can detect a release from any part of the tank and piping. If tanks
and/or piping were installed October 1, 2012, or later, they must be interstitially monitored for releases.
•operate and maintain corrosion protection systems in accordance with WAC 173-360-320 for new or upgraded steel
tanks and piping installed after December 22, 1988.
•provide spill and overfill protection for new or upgraded tanks installed after December 22, 1988, that are filled with
more than 25 gallons at a time.
•report, investigate and clean up any spills and overfills in accordance with WAC 173-360-375.
•use a certified UST supervisor to perform all UST service activities: repairs, tank installation, retrofitting, tank
decommissioning, tightness testing, corrosion protection installation and testing and site assessment.
•notify Ecology of intent to install a new UST system at least 30 days, but not more than 90 days, prior to installation.
•permanently close a tank after it has been temporarily closed or out of service for 12 months and does not meet the
performance standards for new UST systems or the upgrading requirements in WAC 173-360-310(2)(3).
•notify Ecology at least 30 days before beginning either a permanent closure or a change in service.
•have a certified UST supervisor conduct a site assessment at permanent closure or a change-in-service as required
under WAC 173-360-385 through 395.
•not operate an UST or accept delivery of regulated substances without a valid compliance tag.
•notify Ecology within 30 days after bringing any newly installed UST system into use.
•ensure mandatory operator training for Class A, B, and C as required under WAC 173-360-730.
•comply with emergency signage requirement per WAC 173-360-750(2).
Violations of these conditions may result in compliance tag revocation and/or civil penalty up to $5,000 for each tank
involved, for each day of the violation.
As the owner and/or operator of the Underground Storage Tank (UST) system described on this application, I certify
that I have read and agree to abide by the foregoing terms and conditions, and that I understand that having an UST
compliance tag requires that I comply with the provisions contained in chapter 90.76 RCW, the statute governing USTs,
and its implementing regulations, chapter 173-360 WAC.
__________________________________________________________________
Print underground storage tank owner/operator name
__________________________________________________________________
Signature of underground storage tank owner/operator Date
UBI number
V
VI
X
X
BLS-700-042 (05/30/14) PAGE 1 OF 4
Instructions for Completing the Underground Storage Tank Addendum
General information
Please refer to the Underground Storage Tank (UST)
Business Bulletin included with your application packet for
a description of the types of tanks that must be registered
and those which are exempt from registration.
Below are the step-by-step instructions for completing
the Underground Storage Tank Addendum that must
be completed and returned with the Business license
Application.
Read the instructions carefully before answering a
question. Mark your answers only on the Addendum form.
All questions must be answered or your tank registration
may be delayed. Please print your answers clearly in dark
ink. Keep a copy of your completed Addendum, along with
these instructions, in your records for future reference.
You may register all the tanks located at the same site
on one application and addendum. However, you must
complete a separate application and addendum for each
site.You may photocopy and attach additional sheets of the
Section IV page (Individual Tank Information) if you need
more space.
Section I: Tank site information
1.Site location: Give the site name, the on-site phone
number, and address of the physical location of the
tank site (not the mailing address).You may use lati-
tude and longitude coordinates for a remote location if
there is no street address.
2a.Tank owner information:
Enter the name, mailing address and telephone
number of the person or business who owns the
underground storage tanks if different than the
business owner.
2b.Tank operator information:
Enter the name, mailing address and telephone
number of the person/company who is responsible for
operating and maintaining the underground storage
tank operations, if other than business owner.
2c. On-site contact person: Enter the name, mailing
address and telephone number of the person
designated as the underground storage tank site
contact person.
3.Site number: List the six-digit site number issued by
the Department of Ecology (Ecology) UST program.
4.Purpose of application: Mark the appropriate
purpose for which you are filing the application.
•Registeringasthenewownerofanexistingsite.
•Registeringanewsitethathasneverhadtanks
before.
•Registeringanewtankatanexistingsite.
5.Tank site use type (NAICS Code): Below is a partial
list of North American Industry Classification System
(NAICS) codes. Enter the NAICS code assigned to
your site. Choose the category that best describes the
primary business activity performed at the tank site. If
your business activity is not listed below, you can find
a complete list of NAICS codes at your local library or
at the website://www.naics.com
447190 Gasoline service station
445110 Grocery store
611310 College/university
921190 General government
922160 Government fire protection
622110 Hospital
713930 Marina
6.Dispensers:These are the devices used to dispense
regulated substances from an underground storage
tank system.
7.Under-dispenser/pump containment: This indicates
the number of dispensers/pumps with liquid-tight
containment sumps that would catch leaks and drips
from dispenser/pump components.
8.Check the box if you would like a field inspector
to conduct a technical assistance inspection.
Section II: Financial responsibility
information
1.Financial responsibility limits: All owners
of regulated UST's, other than state or federal
government agencies, must provide proof of ability to
pay costs of a release from their tanks at the liability
minimums set in WAC 173-360-400 through 406.Write
the letter of the category that best describes your
facility on the addendum form.
A = Non-marketing facilities with 1-100 tanks, with
average monthly throughput of 10,000 gals.
or less.Requires minimum of $500,000 per
occurrence
with
minimum
of $1,000,000
annual
aggregate.
BLS-700-042 (05/30/14) PAGE 2 OF 4
B = Non-marketing facilities with more than 100
tanks, with average monthly throughput of 10,000
gals. or less.Requires minimum of $500,000 per
occurrence
with
minimum
of $2,000,000
annual
aggregate.
C
= Marketing facilities with 1-100 tanks.Requires
minimum
of $1,000,000 per occurrence
with
minimum
of
$1,000,000 annual
aggregate.
D = Non-marketing facilities with 1-100 tanks with
an average monthly throughput of more than
10,000 gals.Requires minimum of $1,000,000 per
occurrence with minimum of $1,000,000
annual
aggregate.
E
= Marketing facilities with over 100 tanks.
Requires
minimum
of $1,000,000
per occurrence
with
minimum of
$2,000,000 annual
aggregate.
F
= Non-marketing facilities with more than 100 tanks
with an average monthly throughput of more than
10,000 gal.Requires minimum of $1,000,000
per
occurrence
with
minimum
of $2,000,000
annual
aggregate.
G = State or federal government agency.
Presumed self-insured, no proof needed.
2.Method of compliance with financial responsibility
requirement: Indicate which method (as defined in
WAC 173-360-410) you use to meet the minimum
liability limits for your facility.
A
= Approved pollution liability insurance
B= Letter of self-insurance (financial report)
D= Surety bond
E= Letter of credit
F= Trust fund
G= Guarantee
M = State or federal government agency
3.Proof of financial responsibility: For all tank owners,
other than state or federal, if you are registering a new
installation or a change of ownership you must attach
proof of having appropriate pollution liability financial
responsibility. Proof must state site address and
number of tanks. Retrofit applications are not required
to submit the proof.
If using insurance, attach a Certificate of Insurance
from your provider, as set forth in WAC 173-360-480,
listing as the certificate holder:
Business Licensing Service
PO Box 9034
Olympia WA 98507-9034
If you are not using liability insurance, attach a
Certificate of Financial Responsibility as set forth in
WAC 173-360-496.
4.Retroactive Date: Indicate the retroactive date that
is provided on your pollution liability insurance policy.
The retroactive date may or may not be the same as
the effective date of your current/annual policy period.
Usually, the retroactive date is the date you first started
buying pollution liability insurance from that insurance
company. If you have multiple retroactive dates on
your policy, please indicate the oldest retroactive date
on the UST Addendum form.The retroactive date is
the date that insurance coverage begins. Any loss
that occurs before that date will not be covered by the
insurance policy.
Section III: Site plan
Attach a copy of an as built site plan of the tank and
piping installation. Show the nearest streets, adjacent
structures and North arrow. Indicate tank and piping
dimensions and distances to adjacent structures and
property lines. Show the location and configuration of the
completed installation. Indicate the tank name for each
tank shown.The tank name must match the tank name
provided in Section IV, Line A and tank names must be
unique, not used before at this location.
Section IV: Individual tank information
Answer items A through S for each tank at this site. If
a tank has only one compartment, answer items Q, R, and
S in the column for compartment #1; if there are multiple
compartments, answer each item for each additional
compartment as well. Mark all your answers on the
Addendum form.
A Tank name: Enter the identification code for each
tank. If the tank does not already have a particular
identification, choose one for this purpose.This code is
determined by the tank owner or operator and cannot
be more than 12 characters in length. It may simply be
“1”, “2”, “3”, etc., or something which identifies the use
of the tank, such as “diesel,” “unleaded,” etc. No two
tanks at the same site may have the same tank name.
Tank names may not be transferred to another tank at
same site.
B Installation date: Give the month, day, and year
when the tank was originally installed. If this date is
unknown, estimate the date as closely as possible.
Write the date in the following format: Month/Day/Year
(e.g., 06/08/95).
C Tank status: Indicate the current operational status
of the tank. Do not list any tanks exempt from the
underground storage tank registration, as indicated in
the section entitled Tanks Exempt from Underground
Storage Tank Registration on the Underground
Storage Tanks Business Bulletin.
A = Operational
B= Temporarily closed
F = Deferred
BLS-700-042 (05/30/14) PAGE 3 OF 4
D Tank material: Indicate the material from which the
tank is constructed.
A = Steel
C = Fiberglass reinforced plastic
D= Steel clad with corrosion resistant
composite
E = Concrete
F= Dielectric coated steel
O = Other
E1 Tank construction: Indicate how the tank is built.
A= Single walled tank
B = Double walled tank
O = Other
E2 Manifolded tank:
A= Main tank
B= Auxiliary tank
C = Non-manifolded tank
F Tank release detection: Indicate which method is
used.
A= Weekly manual gauging
B= Manual inventory control (daily)
C= Automatic tank gauging
F = Interstitial monitoring (must use this if
installed on or after October 1, 2012)
G = Statistical inventory reconciliation
H= Monthly tank gauging
O = Other
G Tank tightness testing: Indicate which best
describes your testing schedule.
A= Every 5 years
B = Annual
O = Not Required
H Tank corrosion protection: Indicate which best
describes the tank’s protection.
A= Sacrificial anode
B= Impressed current
C= Interior lining
D = Corrosion resistant
F= Sacrificial anode and interior lining
G= Impressed current and interior lining
O = Other
I Spill prevention: Indicate which method is used.
A= Spill bucket/spill box
B= 25 gallons or less
O = Other
J Overfill protection: Indicate which method is used.
A= Automatic shutoff (fill pipe)
B= Overfill alarm
C= Ball float valve (vent line)
D= 25 gallons or less
O = Other
K Piping material: Indicate the material from which the
primary (interior) piping is made.
A
= Steel
C = Fiberglass
D= Flexible piping
E= No piping attached to tank
F= Copper
O = Other
L Piping construction: Indicate how piping is built.
A
= Single walled pipe
B = Double walled pipe
D= Above ground piping
E= No piping attached to tank
O = Other
M1 Piping release detection/primary: Indicate the
primary detection method used.
A= Automatic line leak detector (ALLD)
B= Annual line tightness test (TT)
D= Safe suction (no leak detection)
G = Interstitial monitoring sump or sensor
(must use this if installed on or after
October 1, 2012)
H= No piping attached to tank
I= Statistical inventory reconciliation
J= Not Applicable
K= Elec/ALLD 0.2 gph monthly test
L= Every 3 years line TT (non-safe suction)
O = Other
M2 Piping release detection/secondary: Indicate
the secondary detection method used. Enter "not
applicable" if there is no secondary detection method
used.
A = Automatic line leak detector (ALLD)
B = Annual line tightness test (TT)
D = Safe suction (no leak detection)
G= Interstitial monitoring sump or sensor
H = No piping attached to tank
I= Statistical inventory reconciliation
J= Not applicable
K = Elec/ALLD 0.2 gph monthly test
L= Every 3 years line TT (non-safe suction)
O = Other
Note - Choices that arebolded and italicized are the most common choice.
BLS-700-042 (05/30/14) PAGE 4 OF 4
O1 Piping corrosion protection: Indicate which best
describes the piping’s protection.
A
= Sacrificial anode
B= Impressed current
C= Corrosion resistant
F= No piping attached to tank
O = Other
O2 Steel flex connector at tank:
A = Sump
B= Not in contact with soil
C= Galvanic Anode
D= Rubber boot
E= Impressed current
O3 Steel flex connector at dispenser/pump:
A = Sump
B= Not in contact with soil
C= Galvanic anode
D= Rubber boot
E= Impressed current
P Pumping system: Indicate how the stored product is
moved from the tank to the dispenser/pump.
A= Pressurized system
B= Safe suction
C= Non-safe suction
D= Gravity delivery system (no pump)
E= Product removed by reclaimer
F= Siphon
O = Other
Compartments
If the tank
has
only
one
compartment, answer
the
following items
Q,
R, and S in
the
column for compartment
#1. If there
are
multiple compartments,
answer
each item
for
each additional
compartment
as well.
Q Substance stored: Indicate what is stored, or last
known to have been stored, in the tank.
A= Leaded gasoline
B= Unleaded gasoline
C= Alcohol blend gasoline
D= Diesel
E= Aviation fuel
F= Kerosene
G= Used oil/waste oil
H= Heating fuel
I= Hazardous substance (not antifreeze)
J= Motor oil
K= Antifreeze
M= Bunker C
O= Other petroleum substance
P= Biodiesel blend (greater than B20)
Q= Ethanol blend (greater than E10)
R= Unknown
R Substance use: Indicate how the stored substance
is or was used.
A
= Motor fuel for vehicles
B= Space or process heating
C= Emergency power generation
D= Chemical products (not petroleum)
E= Recycled (used oil)
F= Heating fuel for resale
G= Machinery or engine lubricant.
H= Other
I= Unknown
S Compartment capacity: Indicate the actual capacity
of the compartment in gallons.
Section V: Installers certification
If the tanks were installed or modified after December
29, 1990, the certified installation supervisor must sign the
last page of the form.
Section VI: Owner/operator agreement to
terms and conditions of UST permit
The owner or operator registering the tanks on this
application must read and agree to abide by the terms and
conditions listed on the last page of the form.The owner or
operator must sign the certification statement at the end of
Section VI.
For assistance or to request this document in an alternate format, please call 1-800-451-7985. Teletype (TTY) users may use the Washington Relay Service by calling 711.
