Attachment 10 Form TR-WM-118.pdf

TR-WM-118 (12/14)

Formerly ERS-8731 (R 03/13)

Note: Refer to comments on reverse side of form.

Wisconsin Department of Agriculture, Trade and Consumer Protection

Bureau of Weights and Measures, Storage Tank Regulation

P.O. Box 7837

Madison, WI 53707-7837

(608) 224-4942

FOR OFFICE USE ONLY

TDID#:

Reg Obj #:

Wis. Admin. Code §ATCP 93.140

ABOVEGROUND FLAMMABLE/COMBUSTIBLE/HAZARDOUS LIQUID STORAGE TANK REGISTRATION

Aboveground tanks in Wisconsin that have stored or currently store petroleum or regulated substances must be registered. A separate form is needed for each tank. Send each completed form to the agency designated above. Have you previously registered this tank by submitting a form? Yes No If yes, are you correcting/updating information only? Yes No Personal information you provide may be used for purposes other than that for which it was originally collected (s. 15.04 (1)(m), Wis. Stats.)

This registration applies to a tank status that is (check one):

In Use Ownership Change (Indicate new owner name in block 2-attach deed)

Newly Installed Temporarily Out of Service - Provide Date: _________________

Abandoned with Product Abandoned without Product (empty)

Closed - Tank Removed Closed - Cleaned, Tank not removed

Fire Department providing fire coverage where tank is located:

City Village

Town:

A. IDENTIFICATION (Please Print) Site Street Address Site Telephone Number

1. Tank Site Name

City Village Town: State WISCONSIN Zip Code County

2. Tank Owner Legal Name

Mailing Address Telephone Number

City Village Town: State Zip Code County

3. Property Owner Name (if different than tank owner) Property Owner Address if different than #1

B. Site ID #: Facility ID #: Customer ID #:

C. Tank Capacity (gallons): Tank Age (age or date installed): Vehicle fueling? Yes No

D. LAND OWNER TYPE (check one) Refer to back

County State Federal Leased Federal Owned Tribal Nation Municipal Other Government Private

E. OCCUPANCY TYPE (check one) Refer to back Retail Fuel Sales Bulk Storage Terminal Storage Mercantile/Commercial Industrial Residential School Agricultural (crop or livestock production) Backup or Emergency Generator Gov’t Fleet Utility Other (specify:)

F. Tank Construction:

Bare Steel Coated Steel Stainless steel Steel – Fiberglass Reinforced Plastic Composite Fiberglass or Polyethylene

Concrete Other (specify): If Upgraded by internal lining give date:

Tank Double Walled? Yes No Overfill Protection? Yes No Spill Containment? Yes No

G. Tank Corrosion Protection: Sacrificial Anodes Impressed Current External coating N/A None

H. Primary Tank Leak Detection Method:

Visual monitoring Automatic tank gauging Interstitial monitoring Electronic: NO YES Manual tank gauging

I. Aboveground Piping Construction: Type: Pressurized (includes gravity/head pressure) Suction

Bare Steel Coated Steel Stainless Steel Fiberglass Flexible Copper Unknown NA Other

J. Underground Piping Construction: Type: Pressurized (includes gravity/head pressure) Suction

Bare Steel Coated Steel Stainless Steel Fiberglass Flexible Copper Unknown NA Other

K. Piping Cathodic Protection: Sacrificial Anodes Impressed Current N/A Pipe Double Walled? Yes No

L. Underground Piping Leak Detection Method: Interstitial monitoring Electronic: NO YES Sump or cable sensor Yes No

Tightness testing Electronic line monitor - ELLD Other

M. Containment: Side Material: Earth Concrete/block Steel Synthetic liner

Base Material: Earth Concrete/block Steel Synthetic liner

N. TANK CONTENTS (Current, or previous product (if tank now empty))

Leaded Unleaded Gasohol E85 Diesel Bio-diesel Aviation Premix Fuel Oil Kerosene Unknown

New Oil New oil – Flash point less than 2000F Waste/Used Motor Oil Hazardous Waste/Interface* Empty* Sand/Gravel/Slurry*

Other (specify): Chemical* Name _________________________________________ CAS #:

* If chosen, this tank is NOT PECFA eligible. Geo Latitude: Geo Longitude:

O. If Tank Closed, Abandoned or Out of Service Give date (mo/day/yr):

Has a site assessment been completed? (see reverse side for details) Yes No

Tank Owner Legal Name (please print): E-mail Address

Tank Owner Signature (Note: By signing, signer is accepting legal and financial responsibility for the storage tank system.) Date

TR-WM-118 (12/14)

Formerly ERS-8731 (R 03/13)

Definitions and explanations for completing this form

Land Owner Type - classifies the organization that owns the property the tank is located on. A “Private” landowner is residential, commercial, mercantile, industrial, farm, non-government owned public utility, or other business organization.

Occupancy Type (categories below) – identifies the occupancy in relation to ATCP 93 storage classifications.

Retail Fuel Sales Tank is used to store any fuel product that is offered for sale in the retail market.

Bulk Plant Storage Tank is used to store any fuel product that is offered for sale in the wholesale market.

Industrial Tank is used to store any regulated product associated with an industrial: fleet, heating, industrial fabricating, manufacturing, processing or refining.

Mercantile/Commercial Tank is used to store any regulated product associated with a commercial business fleet, heating, or processing, e.g., service company, medical facility, freight, airport, apartment, etc.

Utility Tank is used to store any regulated product associated with a public or private water or power utility fleet, heating, or processing.

Residential Tank is used to store any regulated product for residential heating or residential automobile fueling.

School Tank is used to store any regulated product at public or private primary, secondary or higher educational institution.

Agricultural Tank is used to store any regulated product directly associated with crop or livestock production, meaning a “farm.” Refer to ATCP 93.050(48)

Back-up or Emergency Generator

Tank is used to store any fuel used to power a backup or emergency generator; a fire pump, or as back-up to a primary fuel source such as fuel oil back-up to a natural gas fired boiler.

Terminal Storage Tank is associated with a distribution facility such as an interstate pipeline. These tanks are typically field erected structures of 500,000 + gallon capacity. A million gallon tank at an ethanol production site would be “industrial,” not “terminal storage.”

Government Fleet Tank is located at a facility owned and operated by a federal, state, county or local government entity. The tank may be used for vehicle fueling, waste oil or heating purposes.

DATCP UST/AST Permit and Registration Group Areas of Responsibility by County

Terri Maus West

Terri Lovicott North East

Israel Zurfluh Central

Gwendolyn Person South East

608-224-5155 608-224-5154 608-224-5152 608-224-5153 02 Ashland 46 Pepin 05 Brown 01 Adams 30 Kenosha

03 Barron 47 Pierce 10 Clark 08 Calumet 40 Milwaukee

04 Bayfield 48 Polk 15 Door 11 Columbia 45 Ozaukee

06 Buffalo 50 Price 19 Florence 13 Dane 51 Racine

07 Burnett 52 Richland 21 Forest 14 Dodge 53 Rock

09 Chippewa 54 Rusk 31 Kewaunee 20 Fond Du Lac 64 Walworth

12 Crawford 55 St Croix 34 Langlade 24 Green Lake 66 Washington

16 Douglas 57 Sawyer 35 Lincoln 28 Jefferson 67 Waukesha

17 Dunn 60 Taylor 37 Marathon 36 Manitowoc

18 Eau Claire 61 Trempealeau 38 Marinette 39 Marquette

22 Grant 62 Vernon 42 Oconto 56 Sauk

23 Green 65 Washburn 43 Oneida 59 Sheboygan

25 Iowa 44 Outagamie 69 Waushara

26 Iron 49 Portage 70 Winnebago

27 Jackson 58 Shawano

29 Juneau 63 Vilas

32 La Crosse 68 Waupaca

33 Lafayette 71 Wood

41 Monroe 72 Menominee

CLOSURE ASSESSMENT INFORMATION

Requirements for a site assessment at the closure or change in service for ATCP 93 regulated aboveground storage tank are outlined in ATCP 93.460 and 93.465.

Closure site assessments (TSSA Form Part B) are to be submitted to the Department as well as the DNR as required in the TSSA Guide:

http://datcp.wi.gov/Consumer/Weights_and_Measures/Storage_Tank_Regulations/index.aspx http://datcp.wi.gov/Consumer/Weights_and_Measures/Storage_Tank_Regulations/index.aspx