PETROLEUM STORAGE TANK
INSTALLATION/REMOVAL/ALTERATION FORM
E nvironm ent
OFFICE USE ONLY
Date Rec’d (yyyy/mm/dd)
Application #
Ext. Ref. #
File #
GPS Co-ordinates
NOTE: This application w ill not be processed unless the department is in receipt of a completed Petroleum
Storage Tank Notification Form.
APPLICATION M UST BE COM PLETED BY the Certified Installer by PRINTING OR TYPING ONLY w ithin
30 days of completion of work on the storage tank system as required under
Section 13(4), 14(3) and/or 15(3) of the Petroleum Management Regulations.
Completion of this application & submission to NS Environment fulfills the requirement for Petroleum Storage
Tank Registration under Section 11 of the Petroleum Management Regulations.
SECTION 1 - TANK OWNER
If there is more than one owner, please indicate who is the primary owner for the petroleum storage tanks and attach a complete list of
owners.
Company/Organization/Municipality
Business Number (BN) if applicable
“
Mr.
“
Ms.
Mrs.
First Name
Phone
Fax (
“
Other:
Professional Designation
Middle Initial
Home (
)
Business (
)
Family Name
)
Ext.
Other (
)
Ext.
E-mail
Civic/Street Address
Mailing Address (if different than Civic)
County
City/Town
Province
Postal Code
Country
SECTION 2 - CONTACT/OPERATOR
Yes “
Is the Contact/Operator the same as Section 1 - Owner?
No “
If yes, please skip to Section 3.
Company/Organization/Municipality
Business Number (BN) if applicable
“
Mr.
“
Ms.
First Name
Phone
Fax (
Mrs.
“
Other:
Professional Designation
Middle Initial
Home (
)
)
Business (
Family Name
)
Ext.
Other (
)
Ext.
E-mail
Civic/Street Address
Mailing Address (if different than Civic)
County
Province
Installation Removal Alteration-appliation.wpd
City/Town
Postal Code
Country
Page 1
November 19, 2015
SECTION 3 - SITE/LOCATION OF ACTIVITIES
Property Identification numbers (PID) are available at the Service Nova Scotia and Municipal Relations.
1:50,000 Topo Maps (identifying Easting and Northing) are available at Nova Scotia Department of the Environment Regional Offices.
Site Name
Civic/Street Address
County
Community
Property Identification # (PID)
1:50,000 Topo Map #
Grid Reference
Easting (6)
Northing (7)
SECTION 4 - ACTIVITY
Activities - Please check (U) all that apply.
Activity
Complete Sections:
U
Petroleum Storage Tank System Registration
Installation
Q
Alteration
Q
5A, 5B, 6 & 7
Removal
Q
SECTION 5 - ACTIVITY DETAILS
Please provide all information requested in metric units indicated.
5 A- Complete only for registration of Petroleum Storage Tank System
Type of Installation:
Bulk Plant
“
Motive Fuel Outlet
“
Marina
“
Commercial
“
Farm
Government
“
Residential
“
“
Other
“
If Other, please specify:
Dyking for Aboveground Tanks
Number of tanks dyked
Concrete “
Dyke Construction Material:
If Other, please specify
Earth/Clay “
Steel “
Synthetic Liner “
Other “
______________________________
Floor Construction Material (please specify)
Length (metres)
Width (metres)
Effective Height (metres)
3
Effective Capacity (length x width x effective height) (metres )
Installation Removal Alteration-appliation.wpd
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November 19, 2015
5B
Description of Tanks
Tank Number (Refer to Drawing)
1.
1
Status of Tank (Mark one only)
2
3
4
5
6
other
Newly Installed
Currently in use
Temporarily out of use
Abandoned in place
Removed
2a. Type of Tank (Aboveground or Underground)
2 b. Compartment tank
3.
Estimated Year of Installation
4.
Estimated Total Capacity (litres)
5.
Material of Construction
a.
Underground Tanks
Steel
Fiberglass reinforced plastic
Unknown
Other, please specify
b.
Aboveground
Tanks Welded Steel
Rivetted steel
Other, please specify
6.
External Protection (Mark all that apply)
Sacrificial anode cathodic protection
Impressed current cathodic protection
Zinc reference electrode
None or Unknown
Other, please specify
7.
Secondary Containment (Mark all that apply)
Double wall
Impermeable liner
Vault
Other, please specify
None
8.
Piping (Mark all that apply)
Coated Black/Bare steel
Galvanized steel
Cathodically protected
Fiberglass reinforced plastic
Flexible piping
Unknown
Other, please specify
9.
Substance currently or last stored (Mark all that apply)
Gasoline
Diesel
Fuel Oil
Kerosene
Bunker
Used oil
Unknown
Other, please specify
10. Additional Information (out of service tanks) - Estimated date last used (mm/yyyy)
Estimated quantity remaining (litres)
Filled with inert material (yes or no)
For Department Use Only
Installation Removal Alteration-appliation.wpd
Registration
Page 3
November 19, 2015
SECTION 6
PETROLEUM STORAGE TANK REPORT
1/ Installation Information
Backfill Material:
Pea Gravel
Other
Geotextile Liner:
Yes “
“
“
Crushed Stone
“
If Other, please specify:
No “
“
Sand
Bed Depth
“
Crusher Dust
Depth of Cover
2/ Closure Plan/Tank Removal Information
Evidence of Leakage: Yes “
No. of tanks removed:
Tank Number
1
2
3
No “
4
5
6
Tank Tag Number * (of removed
tanks)
Tank Capacity (Litres)
Product Last Stored
Tank(s) condition:
Corrosion Free
“
Slightly Pitted “
Yes “
No “
Closure Protocol Followed: Yes “
No “
Yes “
No “
Soil Contamination:
Consultant on Site:
Highly Pitted
Perforated
“
Volume Removed:
Name of Consultant:
Soil Disposal Site:
Tank Disposal Site:
Number of Soil Samples Taken:
Collected By:
Copies of soil sample results sent to Nova Scotia Environment:
“
Yes “
No “
*NOTE: Tank tags for all tanks which have been removed from service shall be returned to
the Nova Scotia Environment with this report.
SECTION 7 - DECLARATION
I hereby certify the inform ation subm itted in this application is true and com plete.
Signature of Certified Installer:
Installer Certificate #
Name (Please print)
Date:
I, the owner, authorize the Certified Installer nam ed above to act on m y behalf to fulfill the requirem ents of the Petroleum
Management Regulations.
Signature of Tank Ow ner:
Date:
Name (Please print)
Installation Removal Alteration-appliation.wpd
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November 19, 2015
M ailing Addresses of Environment Offices in Nova Scotia:
Central Region
W estern Region
Northern Region
Bedford
Kentville
Truro
30 Damascus Road
Suite 115, Bedford Commons
Bedford, NS
B4A 0C1
Phone: (902) 424-7773;
Fax: (902) 424-0597
136 Exhibition Street
Kentville, NS
B4N 4E5
Phone: (902) 679-6086;
Fax: (902) 679-6186
36 Inglis Place
Truro, NS
B2N 4B4
Phone: (902) 893-5880;
Fax: (902) 893-0282
Amherst
Bridgewater
Eastern Region
Sydney
1030 Upper Prince Street
Sydney, NS
B1P 5P6
Phone: (902) 563-2100;
Fax: (902) 563-2387
Port Hawkesbury
218 MacSween Street, Suite 12
Port Hawkesbury, NS
B9A 2J9
Phone: (902) 625-0791;
Fax: (902) 625-3722
Installation Removal Alteration-appliation.wpd
81 Logan Road
Bridgewater, NS
B4V 3T3
Phone: (902) 543-4685;
Fax: (902) 527-5480
71 East Victoria Street
Amherst, NS
B4H 1X7
Phone: (902) 667-6205;
Fax: (902) 667-6214
Antigonish
Yarmouth
55 Starrs Road, Unit 5
Yarmouth, NS
B5A 2T2
Phone: (902) 742-8985;
Fax: (902) 742-7796
155 Main Street, Suite 205
Antigonish, NS
B2G 2B6
Phone: (902) 863-7389;
Fax: (902) 863-7411
Pictou
20 Pumphouse Road
RR #3 New Glasgow, NS
B2H 5C6
Phone: (902) 396-4194;
Fax: (902) 396-4765
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November 19, 2015