UST Insurance Application - Missouri Petroleum Storage Tank ...

APPLICATION FOR UNDERGROUND STORAGE TANK(S)SITESite Name: DNR ST#Site Address: City: State: Zip:OPERATORLegal Entity Name:(Check one) Owner of: Land Tanks Both(Check one) Corporation Partnership or LLC Sole Proprietor GovernmentMailing Address: City: State: Zip:Contact Person: Phone:Email Address: Cell Phone:OWNER (If Different than Operator)Legal Entity Name:(Check one) Owner of: Land Tanks Both(Check one) Corporation Partnership or LLC Sole Proprietor GovernmentMailing Address: City: State: Zip:Contact Person: Phone:Email Address: Cell Phone:CORRESPONDENCE(Please indicate who will be the primary contact for this application and will be responsible for receiving andresponding to our correspondence.)Correspondence regarding this application should be sent to: (Check one) Tank Owner OperatorMORTGAGEELegal Entity Name:Mailing Address: City: State: Zip:Contact Person: Phone:Email Address:Page 1

7. TANK AND PIPING CONSTRUCTION TANK 1 TANK 2 TANK 3 TANK 4 TANK 5A. What material is each tank made of? (steel, fiberglass, STIP-3,ACT 100, etc.)B. Is the tank double-walled? (yes or no)C. Is the tank lined? (yes or no) If yes, enclose a copy of the lininginstallation report and certificate.D. Is the tank cathodically protected? (yes or no) If yes, indicatewhen cathodic protection was installed and enclose acopy of the last cathodic protection test results.E. What is the piping made of? (steel, fiberglass, enviroflex, etc.) Ifsegments or piping run are different materials, show on diagram.F. Is the piping double-walled? (yes or no)G. Is the piping cathodically protected? (yes or no) If yes, indicatewhen the cathodic protection was installed and provide acopy of the last cathodic protection test results.H. Do you have containment under all dispensers at this site? (yes or no)I. Do you have tank top sump containers on top of all tanks/ compartments? (yes or no)8. SPILL AND OVERFILL PREVENTION EQUIPMENT TANK 1 TANK 2 TANK 3 TANK 4 TANK 5A. Do you have single-walled (SW) or double-walled (DW) “spillbuckets”?B. What type of overfill prevention equipment do you have?Automatic Shutoff Device(ASD)Overfill Alarm(OA) Ball Float Valve(BFV)C. Do any of your tanks have remote fills? (yes or no)If yes, what is the piping made of? (steel, fiberglass, etc.)If steel, is there corrosion protection on the piping? (yes/no)9. LEAK DETECTION SYSTEM/TANKS TANK 1 TANK 2 TANK 3 TANK 4 TANK 5A. For each tank, please list your primary leak detection methodand enclose the records. (Refer to the informational flyerdescribing what records to enclose).ATG - automatic tank gauge, IM - interstitial monitoring,DIC - daily inventory control, MTG - manual tank gauging,SIR - statistical inventory reconciliation,VM - vapor monitoring, GWM - groundwater monitoringCITLDS - continuous in-tank leak detection system,VMCM - vapor monitoring with chemical marker,CEIM - continuous, electronic interstitial monitoringB. Is the leak detection being conducted in accordance with theNational Work Group on Leak Detection Evaluations certificationand the manufacturer’s requirements? (yes or no)10. LEAK DETECTION SYSTEM/PIPING LINE 1 LINE 2 LINE 3 LINE 4 LINE 5A. Pressurized Piping (Enclose operability check of line leak detectors)Has a line tightness test been done in the last year? (yes or no)If yes, enclose a copy.B. Suction PipingIs piping sloped so that contents will drain back into the tank ifsuction is released? (yes or no)Is there only one check valve in each suction line? (yes or no)Is the check valve located directly below the pumps? (yes or no)If the answer to any of these is no, please enclose a linetightness test done in the last 3 years.Page 3

DEDUCTIBLE REQUIREMENTSNote: You must provide documents showing how you plan to meet the $10,000 deductible before apolicy can be issued. Please indicate below how you plan to do this, and enclose theappropriate documents as described in the informational flyer. (Check one)Self Insurance*Letter of Credit from a bankCertificate of DepositA GuaranteeAbility to Pay Letter from a bankOther* Enclose a balance sheet showing your assets and liabilities. Net worth must be at least $100,000 orworking capital must be at least $50,000PARTICIPATION FEES(Participation Fees are due and payable with each application. An applicant who owns 50 or morepetroleum storage tanks has the option of paying the participation fees in equal semi-annual installments.)Category One: (Double-walled tank and piping systems) $100 per tank x = $Category Two: (All other fully compliant tank systems) $125 per tank x = $Calculated annual participation fees $One-time $100 New Tank Fee:(Must be paid only once for each tank)$100 per tank x = $Amount enclosed with this application(Make check payable to the PSTIF)$I UNDERSTAND THAT THE FOREGOING INFORMATION IS PROVIDED TO MEET THE FINANCIAL RESPONSIBILITYREQUIREMENTS AS DEFINED BY THE STATE OF MISSOURI FOR UNDERGROUND STORAGE TANKS. ANY FALSE ORMISLEADING INFORMATION AND/OR MISREPRESENTATIONS ARE GROUNDS FOR DENIAL OF CLAIMS AND/ORTERMINATION OF COVERAGE. THIS APPLICATION SHALL BE INCLUDED IN AND MADE PART OF MY PARTICIPATIONAGREEMENT.I CERTIFY THAT THE TANKS MEET OR EXCEED AND ARE IN COMPLIANCE WITH ALL TECHNICAL STANDARDSESTABLISHED BY THE UNITED STATES ENVIRONMENTAL PROTECTION AGENCY AND THE MISSOURI DEPARTMENT OFNATURAL RESOURCES.APPLICANT’S SIGNATURE TITLE DATEAPPLICANT’S PRINTED NAMESubmit to: MISSOURI PST INSURANCE FUNDP.O. BOX 104116JEFFERSON CITY, MO 65110-4116PHONE: 1-800-765-2765 or 573-761-4060Page 4 Rev. 9/12