Fillable Form 400-PS.: Fuel Dispensing And Storage Equipment (SCAQMD)

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Form 400-PS.: Fuel Dispensing And Storage Equipment (SCAQMD)

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South Coast Air Quality Management District, Form 400-E-11 (2014.07)
Mail To:
SCAQMD
P.O. Box 4944
Diamond Bar, CA 91765-0944
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 400-E-11
Fuel Dispensing And Storage Equipment
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and
Form 400-PS.
Page 1 of 5
Section A - Operator Information
Facility Name (Business Name of Operator That Appears On Permit): Valid AQMD Facility ID (Available On Permit Or Invoice Issued By AQMD):
Address where the equipment will be operated (for equipment which will be moved to various location in AQMD’s jurisdiction, please list the initial location site):
Fixed Location Various Locations
Section B - Facility Information
Property Zone
a. Commercial b. Residential
c. Industrial d. Parking e. Other (specify):
Business Type
a. Retail Facility
1. Has the owner/operator attended a SCAQMD approved Rule 461 training course?
No Yes Date of Course Completion:
2. Has the owner/operator developed an Operation and Maintenance manual as required by Rule 461?
No Yes
b. Non-Retail Facility
1. Do you own any fleet vehicles?
No Yes Total number of fleet vehicles:
Operating Schedule
hours/day days/week days/year
Dual or
Multi-
Compart-
ment
Tank?
Number
of Compart-
ments
Tank
No.
Fuel Type
(e.g. Unleaded 87 )
Tank Capacity
(Gallons)
Manifold Location
Under-
ground
At Vent
New Existing Removed
Tank Status
Section C - Equipment Description
1. UNDERGROUND STORAGE TANK INFORMATION: COMPLETE AND CHECK THE APPROPRIATE COLUMNS (Excluding Diesel for Single Compartment Tanks)
a. Provide Phase I CARB Executive Order Number (see instructions):
b. Are any of these storage tanks methanol compatible? No Yes (Identify these tanks):
c. Will any of these storage tanks be located in a vault below grade? No Yes
d. Will a condensate/vapor trap be installed in the vapor return line? No Yes
e. Will the tank(s) at this site contain a remote fill? No Yes
f. Will semi-rigid piping (NUPI or UPP) be used for the vapor return line? No Yes
South Coast Air Quality Management District, Form 400-E-11 (2014.07)
South Coast Air Quality Management District
Form 400-E-11
Fuel Dispensing And Storage Equipment
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and Form 400-PS.
Page 2 of 5
Dual or
Multi-
Compart-
ment
Tank?
Number
of
Compart-
ments
Tank
No.
Fuel Type
(e.g. Unleaded 87)
Tank Capacity
(Gallons)
Tank Dimensions
L x W x H
L x Dia
(Inches)
Phase II CARB
Executive Order
(Table III)
Hose
Length
(Feet)
New
Exist-
ing
Re-
moved
L W (or D) H
Tank Status
Section C - Equipment Description (cont.)
2. ABOVEGROUND STORAGE TANK INFORMATION: COMPLETE AND CHECK THE APPROPRIATE COLUMNS (Excluding Diesel for Single Compartment Tanks)
Residential (ft)
Select One: N NE E SE S SW W NW
Located at:
Commercial/Industrial
(ft)
Select One: N NE E SE S SW
Located at:
3. Indicate the distance and address of the nearest residential and commercial/industrial structures located outside the property line of the facility as measured from the
approximate center of the islands:
4. FUELING POSITION INFORMATION: COMPLETE FOR ALTERATIONS OR NEW CONSTRUCTION
Total Number of Fueling Positions After Alteration or New Construction
:
Total Number of Fueling Positions Prior to Alteration
(for Alterations Only):
Fuel Type
(e.g. Unleaded 87)
# New
Nozzles
# Existing
Nozzles
# Removed
Nozzles
Phase II CARB Executive Order
(Table II)
Maximum Monthly
Throughput
(Gal/Mo)
Maximum Annual
Throughput
(Gal/Yr)
5. NOZZLE INFORMATION: COMPLETE ALL COLUMNS
Change of Throughout Condition:
Total throughput change:
gal/mo
Date of throughput change:
South Coast Air Quality Management District, Form 400-E-11 (2014.07)
South Coast Air Quality Management District
Form 400-E-11
Fuel Dispensing And Storage Equipment
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and Form 400-PS.
Page 3 of 5
THIS IS A PUBLIC DOCUMENT
Pursuant to the California Public Records Act, your permit application and any supplemental documentation are public records and may be disclosed to a third party. If you wish to
claim certain limited information as exempt from disclosure because it qualifies as a trade secret, as defined in the District’s Guidelines for Implementing the California Public Records
Act, you must make such claim at the time of submittal
to the District.
Check here if you claim that this form or its attachments contain confidential trade secret information.
6. GASOLINE PRODUCT INFORMATION: COMPLETE TABLE
# Of Product(s)
(Excluding Diesel)
Number of nozzle(s) dispensing ONE product (grade) of gasoline:
x 1 =
Number of nozzle(s) dispensing TWO product (grade) of gasoline:
x 2 =
Number of nozzle(s) dispensing THREE product (grade) of gasoline:
x 3 =
TOTAL NOZZLE COUNT:
TOTAL PRODUCT COUNT =
7. DISPENSER INFORMATION: COMPLETE AND CHECK THE APPROPRIATE COLUMNS
Dispenser
No. of Similar
Dispensers
Dispenser
No. of Nozzles Per
Dispenser
Make Model No. New Existing Removed Unleaded
Year of Operation Fuel Type Throughput (Gal/Yr)
Gasoline
Gasoline
8. THROUGHPUT INFORMATION: PROVIDE THROUGHPUT RECORDS FOR THE PAST 2 YEARS (EXISTING SITES)
9. For existing gasoline storage and dispensing systems and based on the following, please provide a copy of your MOST RECENT vapor recovery test results.
a. Balance System Tests:
• Static Pressure (Leak-Decay);
• Dynamic Pressure (Back-Pressure); and,
• Liquid Removal (if applicable).
c. Healy Vacuum Assisted System Tests:
• Static Pressure (Leak-Decay);
• Air-to-Liquid Ratio (A/L); and,
• Vapor Return Line.
b. Vacuum Assisted System Tests (Except Healy and Hirt Systems):
• Static Pressure (Leak-Decay); and,
• Air-to-Liquid Ratio (A/L).
d. Vacuum Assisted Hirt System Test:
• Air-to-Liquid Ratio (A/L).
e. For systems not mentioned, provide required test results as per that system’s executive order.
10. Attach a plot plan, a copy of the current Permit to Operate, and other information as directed in Form 400-E-11 Requirements.
Section D - Authorization/Signature
I hereby certify that all information contained herein and information submitted with this application is true and correct.
Preparer
Info
Signature: Date:
Title: Company Name:
Name:
Phone #: Fax #:
Email:
Contact
Info
Name:
Title: Company Name:
Phone #: Fax #:
Email:
Validate/Print
Reset
South Coast Air Quality Management District, Form 400-E-11 (2014.07)
South Coast Air Quality Management District
Form 400-E-11
Fuel Dispensing And Storage Equipment
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and Form 400-PS.
Page 4 of 5
FORM 400-E-11 REQUIREMENTS
WHO MUST APPLY FOR A PERMIT:
A fuel dispensing and storage equipment permit application is required for any new installation, alteration, facility with an expired permit or change of
permit condition.
WHEN TO APPLY:
Prior to any new construction, alteration, or change of permit condition. An application shall be filed prior to use if ownership has changed. Installing
any equipment contrary to the Permit to Construct or to the information provided in this form without notifying the AQMD engineer will void this
application or your permit, and will require submittal of a new application and associated fees. Sites with expired permits or existing equipment
operating without permit shall apply as soon as possible to avoid possible enforcement action. Sites requesting a change of permit condition must
receive new permit approval prior to dispensing requested throughput change.
HOW TO APPLY:
A. Fill out Forms 400-A, 400-E-11, and 400-CEQA for each facility for new construction, alteration, change of permit condition, and
reinstatement of expired permits.
If AQMD has identified your facility as a Title V facility, use the telephone numbers in Section B below to obtain further assistance.
B. The proper filing fee is found in Rule 301. Checks or money orders should be made payable to the South Coast Air Quality Management
District. Send the completed application to: SCAQMD, P. O. Box 4944, Diamond Bar CA 91765. Further information may be obtained by
calling (909) 396-2468, (909) 396-2469, or (909) 396-2470.
C. Submit equipment location drawings which shall be to scale (suggested scale: 1 inch = 100 feet; accuracy of measurements to the nearest 5
feet will be satisfactory) and shall show at least the following:
1. The property involved and outlines of all buildings. Identify property lines plainly.
2. Location and identification of the proposed equipment on the property.
3. Location of the property with respect to streets and all adjacent properties. Identify adjacent properties. Identify buildings or vacant lots
outside the property lines.
Identify all such buildings as residential and commercial/industrial. Indicate direction (north) on the drawing.
4. Drawings showing all tanks, vapor recovery and product piping with pipe diameters to be installed, provide details of dispensing
nozzles, vapor return connectors, vent pipe location, and vapor processing systems (if any). Any vapor recovery system being installed
or operated must be of a type certified by the California Air Resources Board.
5. Drawings showing all islands, dispensers, and fueling positions (before and after alterations or for new construction).
D. For all existing sites, submit annual gasoline throughput records and days of operation for the last two years.
NOTICE: Construction or operation prior to receipt of Permit to Construct or Operate constitutes a violation of the Rules and Regulations of the
SCAQMD.
VAPOR RECOVERY SYSTEMS:
Rule 461 (c)(1) regulates the transfer of gasoline and methanol from delivery vehicles to storage tanks and requires installation of CARB certified
submerged fill pipes, spill boxes, and vapor return equipment (Phase I vapor recovery). Phase I vapor recovery transfers these vapors from the
storage tank into the unloading delivery vehicle so that it can be transported back to the terminal vapor processor for recovery or destruction.
Rule 461 (c)(2) regulates the transfer of gasoline and methanol into motor vehicle tanks larger than five gallons. A special fill nozzle and vapor
piping allow these vapors to be returned from the vehicle fuel tank to the storage tank or to vapor processing equipment (Phase
II vapor
r
ecovery).
For aboveground tanks and mobile refuelers dispensing gasoline or methanol, the standard Phase I and Phase II vapor control systems must be
installed for compliance. Rule 461 also requires the installation of a pressure-vacuum relief valve.
UNDERGROUND TANK AND PIPING REQUIREMENTS:
Rule 1170(c)(1) states that after July 1, 1988 a person shall not install or allow the installation of any new underground fuel storage tank(s) unless
at least one such tank at any single motor vehicle fueling facility, along with all associated underground pipes is capable of safely storing and
transporting methanol fuel, as evidenced by written certification from the manufacturer for the useful life of the tank. In addition, all gasoline
equipment shall be installed, equipped, and operated with CARB certified equipment (submerged fill tubes, spill boxes, etc.). Furthermore, all new
gasoline tanks shall be manifolded underground and be equipped with a two-point Phase I design.
South Coast Air Quality Management District, Form 400-E-11 (2014.07)
South Coast Air Quality Management District
Form 400-E-11
Fuel Dispensing And Storage Equipment
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and Form 400-PS.
Page 5 of 5
FORM 400-E-11 INSTRUCTIONS
FUEL TYPE:
Provide the type of fuel stored in each tank (e.g. gasoline grades, diesel, or methanol).
TABLE I - CARB EXECUTIVE ORDERS FOR PHASE I VAPOR RECOVERY SYSTEMS*
Standard ^ (Non-EVR) G-70-97-A
^ Standard cannot be used on new installations after 7/1/01
EBW-EVR VR-103
Phil-Tile Enhanced vapor Recovery (EVR) VR-101 CN1 Manufacturing-EVR VR-104
OPW-EVR VR-102 EMCO Wheaton-EVR VR-105
* If the system is not mentioned, provide CARB Executive Order (EO) Number.
* If the system is not mentioned, provide CARB Executive Order (EO) Number.
TABLE III - CARB EXECUTIVE ORDERS FOR PHASE II VAPOR RECOVERY SYSTEMS* (ABOVEGROUND TANKS):
Above Ground Tank Vault G-70-160 Healy Model 400-ORVR G-70-187
Bryant G-70-168 Hoover Fuelmaster G-70-161
Containment Solutions Hoover Vault G-70-194 LRS Fuelmaster G-70-133-A
Convault G-70-116-F Lube Cube G-70-148-A
Cretex Fuel Vault G-70-195 Moiser Brothers G-70-152
Ecovault (Balance) G-70-157 P/T Vault G-70-143
Ecovault (Vacuum Assist) G-70-156 Petroleum Marketing G-70-155
Enviro Vault G-70-167 Petrovault G-70-130
Firesafe G-70-136 San Luis Firesafe G-70-158-A
Fuelsafe G-70-137 Steel Tank Fireguard G-70-162-A
Guardian Containment Armor Cast G-70-190 Supervault G-70-132-B
Hasstech VCP-3A G-70-175 Tank Vault G-70-131-A
EVR Standing Loss (Existing) VR-301 EVR Standing Loss (New) VR-302
* If the system is not mentioned, provide CARB Executive Order (EO) Number.
FUEL POSITIONS:
The number of fueling positions is equal to the number of nozzles that can mechanically and electronically be operated at the same time.
A. 3 Fueling Positions B. 2 Fueling Positions C. 4 Fueling Positions
GASOLINE PRODUCTS
Complete table by identifying the number of gasoline nozzles that dispenses either one, two, or three products (grades). Compute the overall total nozzle count and
total product count.
SIGNATURE OF RESPONSIBLE MEMBER OF ORGANIZATION
This form shall be signed by a responsible person from the company applying for the permit, rather than by the contractor working on the project. In addition, include a
telephone number where this person can be contacted for additional information regarding this application.
NOTE: IF FORM 400-E-11 IS INCOMPLETE, THE APPLICATION WILL BE RETURNED
TABLE II - CARB EXECUTIVE ORDERS FOR PHASE II VAPOR RECOVERY SYSTEMS* (UNDERGROUND TANKS):
Healy without ISD VR-201 VST with Veeder-Root Carbon Canister and ISD VR-204 (VR)
Healy with Veeder-Root ISD VR-202 (VR) VST with Hirt Thermal Oxidizer without ISD VR-205
Healy with Incon ISD VR-202 (Incon) EMCO Wheaton/Hirt Phase II EVR without ISD VR-207
VST without ISD VR-203 EMCO Wheaton/Hirt Phase II EVR with ISD VR-208
VST with VST Cell Membrane and ISD VR-204 (CM)
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Completed 12 August 2020

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