Fillable Form 0724 Form 0724 - 0724 (U.S. State of Texas)

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Form 0724 Form 0724 - 0724 (U.S. State of Texas)

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TCEQ-0724 (Rev. 1/2016)
PST Rules are located in Title 30 TAC, Chapter 334 Page 1 of 5
Owner’s Customer No.: CN Facility’s Regulated Entity No.: RN
TCEQ - UNDERGROUND STORAGE TANK REGISTRATION & SELF-CERTIFICATION FORM
(Use this form for filing registration and self-certification information) Page 1 of 5
For Use
in
TEXAS
Texas
Commission
On
Environmental
Quality
● Please mail completed form to:
Petroleum Storage Tank Registration Team (MC-138)
Texas Commission on Environmental Quality
P. O. Box 13087
Austin, Texas 78711-3087
(512) 239-2160 Fax (512)239-3398
*MAKE A COPY OF FORM FOR YOUR RECORDS*
TCEQ Facility ID
No.
:
TCEQ Owner ID No.:
Federal Tax ID No. :
1. TANK OWNER INFORMATION
TANK OWNER BUSINESS OR LAST NAME:
TANK OWNER FIRST NAME
TYPE OF TANK OWNER:
Individual Corporation Common Carrier Railroad
Federal Gov’t State Gov’t Local Gov’t
County Gov’t City Gov’t Sole Proprietorship
OWNER MAILING ADDRESS
L
OCATION
OF RECORDS:
At facility Offsite at:
CITY:
S
TATE
: Z
IP
C
ODE
:
OFFSITE RECORDS LOCATION ADDRESS CITY STATE
COUNTRY (OUTSIDE USA)
E-MAIL ADDRESS
RECORDS CUSTODIAN/CONTACT PERSON: TELEPHONE NO.
OWNER’S AUTHORIZED REPRESENTATIVE TITLE:
T
ELEPHONE
N
O
.
FAX NO:
INDEPENDENTLY OWNED & OPERATED
YES NO
STATE FRANCHISE TAX ID
DUNS NO
NUMBER OF EMPLOYEES
0-20 21-100 101-250 251-500 501 & HIGHER
** For Self-Certification only this form will not be processed until all delinquent fees and/or penalties owed to the TCEQ or the
Office of the Attorney General on behalf of the TCEQ are paid in accordance with the Delinquent Fee and Penalty Protocol. **
2. FACILITY INFORMATION
FACILITY NAME:
TYPE OF FACILITY: Emergency Generator Wholesale
Retail Farm
or Residential Fleet Refueling
Aircraft Refueling Indian Land Watercraft Fueling
Industrial/Manufacturing/Chemical Plant
Number of regulated *USTs at this facility:
*Underground Storage Tanks (USTs)
Number of regulated *ASTs at this facility:
*Aboveground Storage Tanks (ASTs)
PHYSICAL LOCATION:
CITY:
TX
Z
IP
C
ODE
C
OUNTY
:
ON-SITE CONTACT PERSON TITLE: TELEPHONE NO.:
PRIMARY SIC CODE
SECONDARY SIC CODE
E_MAIL ADDRESS: FAX NUMBER
PRIMARY NAICS CODE SECONDARY NAICS CODE
LATITUDE
Degrees
Minutes Seconds
LONGITUDE
Degrees
Minutes Seconds
*** PRIOR TO RETAIL SALE OF FUEL TO THE PUBLIC USING MEASURED DISPENSING DEVICES, ANY METER MUST BE
REGISTERED WITH THE TEXAS DEPARTMENT OF AGRICULTURE 1-800-TELL-TDA (1-800-835-5832).
3. TANK OPERATOR*INFORMATION
(mark here if same as owner)
* “Operator” means any person in day-to-day control of, and having responsibility for, the daily operation of the UST system.
TCEQ Operator ID No.:
(Assigned by TCEQ)
CN
TANK OPERATOR NAME: (DO NOT LIST EMPLOYEES OF OPERATOR)
TYPE OF TANK OPERATOR:
Individual Corporation
Sole Proprietorship Federal Gov’t
State Gov’t County Gov’t
Local Gov’t City Gov’t
Date listed person became operator:
MAILING ADDRESS:
CITY: STATE:
Z
IP
C
ODE
:
OPERATOR’S AUTHORIZED
REPRESENTATIVE:
T
ITLE
:
T
ELEPHONE
N
O
:
_RE_
_UST
PST _
For internal use only
TCEQ-0724 (Rev. 1/2016)
PST Rules are located in Title 30 TAC, Chapter 334 Page 2 of 5
TCEQ Facility ID No
TCEQ- UST REGISTRATION & SELF-CERTIFICATION FORM
***MAKE A COPY OF FORM FOR YOUR RECORDS***
For Self-Certification Annual Renewal, Sections 1 thru 5 and 7 thru 9 must be completed. If there are any changes including change of
ownership along with the renewal of the delivery certificate, Sections 1 thru 5 and 7 thru 10
& 12 must be completed.
For Initial Registration, Sections 1 thru 13, the complete form should be completed.
For data verification purposes, please check our IWR (Integrated web reporting) web page
www15.tceq.texas.gov/crpub/index.cfm?fuseaction=regent.RNSearch
If you have any questions on how to fill out this form or about the PST Registration program, please contact us at
512/239-2160.
Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors
in their information corrected. To review such information, contact us at 512-239-2160.
4. REASON FOR THIS FILING
PART
A).
UST
R
EGISTRATION
I
NFORMATION (Mark all that apply):
1
Initial Registration
2
UST Ownership Change (New Owner indicate effective date :)
3
Amendment of:
A
Owner Information
B
Operator Information
C
Facility Information
D
UST System Information
E
Financial Assurance Information
4
Operator Training
5.
Other (specify):
PART
B).
UST
C
OMPLIANCE
S
ELF
-
C
ERTIFICATION
I
NFORMATION (Mark all that apply):
1
Initial Certification at Facility (Including Tank Ownership Change)
2
Annual Renewal
3
New Tank at Facility
4
Other (specify):
5. TCEQ PROGRAMS IN WHICH THIS REGULATED ENTITY PARTICIPATES
Check all Programs and write in the permits/registration numbers that will be affected by the updates submitted on this form or the updates
may not be made. If the program is not listed, check other and write it in.
Animal Feeding Operation Dam Safety Districts
Industrial & Hazardous Waste Municipal Solid Waste New Source Review - Air
OSSF Petroleum Storage Tank Sludge
Stormwater Tires Title V - Air
Utilities Voluntary Cleanup Program Wastewater Agriculture
Wastewater Permit Water Districts Water Rights
Water Utilities Other Other
Unknown Licensing - Type(s)
6.
OPERATOR TRAINING
Each class of operator – Class A, Class B, and Class C shall be trained and certified in accordance with Title 30, TAC 334
Subchapter N. Class A and Class B Operators must ensure that training certificates are maintained at each facility
. A copy of the
initial or new certificate must also be provided to the TCEQ with their annual self certification starting August 8, 2012. All classes
of operators must be retrained within three years of their training date.
As of the signature date on this form, this site is in compliance with all Class A, B, and C UST facility operator training: Yes No
Class A Operator (Exactly as it appears on certificate)
First Name Last Name
Training Provider Date of Training
Class B Operator – Check Box if Same as Class A Operator
First Name Last Name
Training Provider Date of Training
TCEQ-0724 (Rev. 1/2016)
PST Rules are located in Title 30 TAC, Chapter 334 Page 3 of 5
TCEQ Facility ID No.
TCEQ- UST REGISTRATION & SELF-CERTIFICATION FORM
7
.
SELF
-
CERTIFICATION
OF
COMPLIANCE
WITH
UST
REQUIREMENTS
Important:
Completion of this section is required before TCEQ issues a UST Delivery Certificate. Delivery of regulated substances into r
egulated USTs
is prohibited by state law unless a valid, current Delivery Certificate is available and/or displayed at the UST facility. Any responses marked ANO@
, or
any incomplete submittal, will result in non
-
issuance of a Delivery Certificate for this facility.
●
INDICATE RESPONSES TO EACH QUESTION BY MARKING X IN THE APPROPRIATE SPACE AT THE RIGHT.
YES
NO
REGISTRATION
●
For regulated UST systems at the facility indicated below, is the registration information filed with the TCEQ
pursuant to §334.7 of TCEQ rules (including information in this filing) complete, accurate, & up-to-date?
FACILITY FEES
●
For regulated UST systems at the facility indicated below, have all facility fees billed to date to the current
owner been paid in full (I.e., annual fees p
lus all late fees, penalties, & interest)? (Does not apply to
common carrier railroads)
FINANCIAL
ASSURANCE
●
For regulated UST systems at the facility indicated below, does financial assurance coverage meet TCEQ
requirements, as described in Chapter 37 Subchapter I of TCEQ rules, for first-party corrective action,
third-party bodily-injury, and third-party property damage in the event of a petroleum release from these
UST systems?
TECHNICAL
STANDARDS
●
For regulated UST systems at the facility ind
icated below, are all in compliance with technical standards,
as described in TCEQ rules in §334.49 (relating to Corrosion Protection), §
334.50 (relating to Release
Detection), §334.51 (relating to Spill and Overfill Prevention and Control) and §334.43 (re
lating to Variances
and Alternative Procedures
) if a written variance to all or part of the requirements of the previous three
sections has been granted by the TCEQ? (A AYes@ response indicates that recordkeeping
requirements and reporting duties have bee
n met for 60 days prior to and including the date of
certification.)
I am certifying that the following UST systems at this facility are in compliance:
Tank ID #(s) as numbered on Pages 4 and 5 of this form.
If certifying more UST systems, please list additional ID #s on another form.
This Self-Certification will not be processed or Delivery Certificate created unless Proof of Financial Assurance has been provided
with this form. (State & Federal Entities Exempt)
8
. FINANCIAL ASSURANCE INFORMATION
Financial Assurance (Petroleum USTs only)
Does this facility meet Financial Assurance (FA) requirements for both
1
st
party corrective action and 3
rd
party bodily injury/property damage liability? Yes No Exempt (state and federal entities only)
If YES, identify FA mechanism(s): Insurance (or risk retention group) Financial test Guarantee* Letter of credit*
Surety bond* Local Gov. financial test ** Local Gov. guarantee** Trust fund
*
A
lso
requires
stand
-
by trust fund.
** O
nly
available to
local governments (counties, municipalities, and special districts
).
Information pertaining to the
financial assurance mechanism(s) used to demonstrate financial assurance under
Chapter 37, Subchapter I of Title 30, Texas Administrative Code is as follows:
Name of Issuer: Phone # of Issuer: Policy or mechanism #:
Coverage period
Beginning: Ending:
Coverage Amount s: Occurrence $
Annual Aggregate $
Insurance Premium pre-paid for entire year?***
k Yes No***For information purposes only
**
For questions regarding Financial Assurance, call the Financial Assurance Section at (512) 239
-
0300
**
9
. TANK OWNER/OPERATOR SELF
-
CERTIFICATION (for Delivery C
ertificate)
I hereby certify under penalty of law to the following:
● I am the (mark one): owner . . . legally-authorized representative of the owner . . .
operator . . . legally-authorized representative of the operator . . .
. . . of the regulated underground storage tank (UST) systems at this facility; AND
● I have personally examined and am familiar with the information included in Sections 1 through 4 AND 7; AND 8
● Based on my current knowledge and understanding, the submitted information is true, accurate, and complete; AND
●
I understand t
hat any person who intentionally or knowingly submits false information on this form is subject to criminal prosecution.
P
RINTED
N
AME OF
O
WNER
/O
PERATOR
(
OR
A
UTHORIZED
R
EPRESENTATIVE
)
T
ITLE
S
IGNATURE OF
O
WNER
/O
PERATOR
(O
R
A
UTHORIZED
R
EPRESENTATIVE
)
D
ATE OF
S
IGNATURE
(
PLEASE PRINT
)
10
. TANK OWNER/OPERATOR REGISTRATION (for Initial Registration or Changes)
I hereby represent the following:
● I am the (mark one): owner . . . legally-authorized representative of the owner . . .
operator . . . legally-authorized representative of the operator . . .
. . . of the regulated underground storage tank (UST) systems at this facility; AND
● I have personally examined and am familiar with the information included in Sections 1 through 5, and Sections 8, 11 - 13; AND
● Based on my current knowledge and understanding, the submitted information is true, accurate, and complete and that I have signature
authority to submit this form on behalf of the entity in Section 1 and/or as required for the updates to the ID numbers identified in Section 5;
AND
● I understand that any person who intentionally or knowingly submits false information on this form is subject to criminal prosecution.
P
RINTED
N
AME OF
O
WNER
/O
PERATOR
(
OR
A
UTHORIZED
R
EPRESENTATIVE
)
T
ITLE
S
IGNATURE OF
O
WNER
/O
PERATOR
(O
R
A
UTHORIZED
R
EPRESENTATIVE
)
D
ATE OF
S
IGNATURE
(
PLEASE PRINT
)
TCEQ-0724 (Rev. 1/2016)
PST Rules are located in Title 30 TAC, Chapter 334 Page 4 of 5
TCEQ Facility ID No.
TCE
Q- UST REGISTRATION & SELF-CERTIFICATION FORM
11
.
INSTALLER/ON
-
SITE
SUPERVISOR
CERTIFICATION
NOTE: This section must be completed and signed by the Installer or On-Site Supervisor.
Leave blank if no tank or underground line installation activity is involved.
Was tank and/or line testing completed during and after installation? Yes No
D
ATE
(
S
)
I
NSTALLATION ACTIVITIES PERFORMED
:
C
ONTRACTOR
(C
OMPANY OR
F
IRM
):
TCEQ
CRP
N
O
.:
CRP
I
NDIVIDUAL
I
NSTALLER
/
O
N
-
S
ITE
S
UPERVISOR
:
TCEQ
ILP
N
O
.:
ILP
● I hereby certify that the information provided concerning recent installations were conducted by me or under my direct supervision, that
I am familiar with the TCEQ requirements applicable to such activities and that to the best of my knowledge and belief such
activities were performed in conformance with applicable TCEQ UST regulations.
● SIGNATURE OF INSTALLER/SUPERVISOR: DATE OF SIGNATURE
Important: The information in the following sections regarding the UST system(s) at this facility must be properly
completed in sufficient detail to support registration. UST owners & operators are encouraged to examine their UST
records and/or consult with their UST equipment installers, service technicians, and/or insurance providers to ensure
that this information is accurate and complete.
12. TANK IDENTIFICATION/DESCRIPTION
Tank Identification Number each tank compartment at
your site consistent with Rule 334.8(c)(5)(C).
Tank Installation Date (Month/day/year)
Tank Capacity (in U.S. gallons)
Tank Status
(Mark One Status & Indicate Date, if
Applicable)
1-Currently in Use
2-Temporarily out of service (date)
- Meets TCEQ Definition of Empty?-Yes or No
3-Perm.filled in place w/ sand, concrete, etc.(date)
4-Permanently removed from the ground (date)
1-
2-
Yes No
3-
4-
1-
2-
Yes No
3-
4-
1-
2-
Yes No
3-
4-
1-
2-
Yes No
3-
4-
Current/Last Substance Stored
(Mark All that Apply
1-Gasoline
2-Diesel
3-Kerosene
4-Used Oil
5-New Oil
6–Other Petroleum Substance (specify)
7a-CERCLA Hazardous Substance (specify)
7b-Chemical Abstract Service (CAS) No.
7c-Hazardous Substances Mixture (specify)
8-Petroleum/Hazardous Substances Mixture
(specify)
1-
2-
3-
4-
5-
6-
7a-
7b- #
7c-
8-
1-
2-
3-
4-
5-
6-
7a-
7b- #
7c-
8-
1-
2-
3-
4-
5-
6-
7a-
7b- #
7c-
8-
1-
2-
3-
4-
5-
6-
7a-
7b- #
7c-
8-
13. UST SYSTEM TECHNICAL INFORMATION
Tank & Piping Design
(Mark One for Tank & Piping)
1-Single-Wall
2-Double-Wall
External Containment (Mark all that apply)
3-Factory-Built Nonmetallic Jacket
4a-Synthetic Tank-Pit/Piping-Trench Liner
4b-Tank Vault/Rigid Trench Liner
Type of Piping (Mark One)
5a-Pressurized
5b-Suction
5c-Gravity
Tank Internal Protection
6-Internal Tank Lining (Indicate date)
Tank
Piping
1-
2-
3-
4a-
4b-
5a-
5b-
5c-
6-
Tank
Piping
1-
2 -
3-
4a-
4b-
5a-
5b-
5c-
6-
Tank
Piping
1-
2 -
3-
4a-
4b-
5a-
5b-
5c-
6-
Tank
Piping
1-
2-
3-
4a-
4b-
5a-
5b-
5c-
6
TCEQ-0724 (Rev. 1/2016)
PST Rules are located in Title 30 TAC, Chapter 334 Page 5 of 5
TCEQ Facility ID No.
TCEQ
- UST REGISTRATION & SELF-CERTIFICATION FORM
13. UST SYSTEM TECHNICAL INFORMATION – CONTINUED FROM PAGE 4
Tank Identification
(e.g. 1, 2, 3, 4, etc.)
Tank & Piping Materials
(Mark all that apply)
1-Steel
2-FRP (fiberglass-reinforced plastic)
3-Composite tank (steel w/external FRP cladding)
4-Concrete
5a-Jacketed (steel w/external nonmetallic jacket)
5b-Coated (steel w/external polyurethane cladding)
5c-Nonmetallic flexible piping
Piping Connectors & Valves (Mark all that apply)
6-Shear/Impact Valves (under dispenser)
7-Steel swing-joints (at ends of piping)
8-Flexible connectors (at ends of piping)
Tank
Piping
1 -
2 -
3 - N/A
4 -
5a-
5b- N/A
5c-N/A
6-N/A
7
-N/A
8-N/A
Tank
Piping
1 -
2 -
3 - N/A
4 -
5a-
5b- N/A
5c-N/A
6-N/A
7
-N/A
8-N/A
Tank
Pip
ing
1 -
2 -
3 -
N/A
4 -
5a-
5b- N/A
5c-N/A
6-N/A
7-N/A
8-N/A
Tank
Piping
1-
2 -
3 -
N/A
4 -
5a-
5b-
N/A
5c-N/A
6-N/A
7-N/A
8-N/A
Tank/Piping Corrosion Protection
(Mark all that apply)
1-External dielectric coating/laminate/tape/wrap
2a-Listed/certified factory-installed cathodic protection
2b-Certified field-installed cathodic protection
3a-Listed composite tank (steel w/FRP external laminate)
3b-Listed coated tank (steel w/external polyurethane laminate)
4a-Listed FRP tank or piping (non-corrodible)
4b-Listed nonmetallic flexible piping (non-corrodible)
5a-Listed/certified external nonmetallic jacket
5b-Isolated in open-area (e.g., sump, boot, etc.) or
secondary containment device (e.g., wall, jacketed or
liner)
6-Dual protected
7-Unnecessary per corrosion protection specialist
Tank
Piping
1-
2a-
2b-
3a- N/A
3b- N/A
4a-
4b-N/A
5a- N/A
5b- N/A
6- N/A
7-
Tank
Piping
1-
2a-
2b-
3a- N/A
3b- N/A
4a-
4b-N/A
5a- N/A
5b- N/A
6- N/A
7-
Tank
Piping
1-
2a-
2b-
3a-
N/A
3b-
N/A
4a-
4b-N/A
5a- N/A
5b- N/A
6- N/A
7-
Tank
Piping
1-
2a-
2b-
3a-
N/A
3b-
N/A
4a-
4b-N/A
5a- N/A
5b- N/A
6- N/A
7-
Tank & Piping Release Detection
(Mark all that apply)
1-External vapor/tracer monitoring
2-External groundwater monitoring
3-Monitoring of secondary containment barrier
4-Automatic tank gauge test & inventory control
5-Interstitial monitoring within secondary wall/jacket
6a-Monthly piping tightness test (@ 0.2 gph)
6b- Annual piping tightness test /
Annual electronic monitoring (@ 0.1gph)
6c-Triennial tightness test (for suction/gravity piping)
6d-Auto. line leak detector (3.0gph for pressure piping)
7a-Weekly manual tank gauging (tanks ≤ 1,000 gal)
7b-Monthly tank gauging (for emer. generator tanks)
8-SIR-Statistical Inventory Reconciliation & inv. Control
9-Exempt system suction
Tank
Piping
1-
2-
3-
4- N/A
5-
6a-N/A
6b-N/A
6c-N/A
6d-N/A
7a- N/A
7b- N/A
8-
9- N/A
Tank
Piping
1-
2-
3-
4- N/A
5-
6a-N/A
6b-N/A
6c-N/A
6d-N/A
7a- N/A
7b- N/A
8-
9- N/A
Tank
Piping
1-
2-
3-
4-
N/A
5-
6a-N/A
6b-N/A
6c-N/A
6d-N/A
7a-
N/A
7b-
N/A
8-
9- N/A
Tank
Piping
1-
2-
3-
4-
N/A
5-
6a-N/A
6b-N/A
6c-N/A
6d-N/A
7a-
N/A
7b-
N/A
8-
9- N/A
Spill Containment & Overfill Prevention Equipment
1- Tight-fill fitting
2- Factory-built spill container/bucket/sump
3a-Delivery shut-off valve (set@ ≤95%capacity)
3b-Flow restrictor valve, e.g., vent ball-float (set@ ≤90% cap.)
3c-Alarm (set@ ≤90%), w/3a or 3b (set@ ≤98% cap.)
4 - N/A - All deliveries to tank are ≤ 25 gal. each
1 -
2 -
3a-
3b-
3c-
4 -
1 -
2 -
3a-
3b-
3c-
4 -
1 -
2 -
3a-
3b-
3c-
4 -
1 -
2 -
3a-
3b-
3c-
4 -
Stage I Vapor Recovery
* See 30 TAC 115 for rule & location exemption information.
1-Stage I (UST to tanker truck): Installation date:
• Type: 1a-Stage I two-point system
1b-Stage I coaxial system
• Exempt by: 1c-TCEQ Rule*
1-
1a-
1b-
1c-
1-
1a-
1b-
1c-
1-
1a-
1b-
1c-
1-
1a-
1b-
1c-
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Form 0724 Form 0724 - 0724 (U.S. State of Texas)

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Completed 18 July 2020

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