"Storage Tank Interior Painting Project Application" - Connecticut

Storage Tank Interior Painting Project Application is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on June 13, 2012;
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Download "Storage Tank Interior Painting Project Application" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
STORAGE TANK INTERIOR PAINTING PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for a project which comprises the
painting/coating and associated repairs of an existing storage tank, and must be submitted to the Department
of Public Health (DPH) along with a General Application Form. A document entitled “Storage Tank Design and
Construction Guidelines” is available on the DPH’s web site
http://www.ct.gov/dph/publicdrinkingwater
for use
as a reference in planning and design of a tank project. Supporting information as identified with an asterisk (*)
in this application will need to be provided. Specific and applicable RCSA or CGS will be stated within
brackets [ ]. Check off and complete all items that apply to the proposed project.
Section A. General Information
PWS Name:
PWSID #: CT
Please provide the contact information of the primary person who can answer technical questions regarding this
project:
Name:
Title:
Company:
Address:
Phone Number:
Fax Number:
E-mail Address:
Section B. Type of Tank(s) to be painted
Gross volume (gal./tank):
Standpipe (atmospheric)
Ground Level (atmospheric)
Material of tank:
welded steel;
bolted steel;
concrete;
other
Buried/Bulkheaded (atmospheric)
Elevated (atmospheric)
Hydropneumatic/Pressure
Other:
Section C. Time Frame for Project Implementation (approximate dates)
Date tank to be taken out of service:
Date tank is to be back in service:
rev 06.13.2012
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Storage Tank Interior Painting Project Application
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
STORAGE TANK INTERIOR PAINTING PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for a project which comprises the
painting/coating and associated repairs of an existing storage tank, and must be submitted to the Department
of Public Health (DPH) along with a General Application Form. A document entitled “Storage Tank Design and
Construction Guidelines” is available on the DPH’s web site
http://www.ct.gov/dph/publicdrinkingwater
for use
as a reference in planning and design of a tank project. Supporting information as identified with an asterisk (*)
in this application will need to be provided. Specific and applicable RCSA or CGS will be stated within
brackets [ ]. Check off and complete all items that apply to the proposed project.
Section A. General Information
PWS Name:
PWSID #: CT
Please provide the contact information of the primary person who can answer technical questions regarding this
project:
Name:
Title:
Company:
Address:
Phone Number:
Fax Number:
E-mail Address:
Section B. Type of Tank(s) to be painted
Gross volume (gal./tank):
Standpipe (atmospheric)
Ground Level (atmospheric)
Material of tank:
welded steel;
bolted steel;
concrete;
other
Buried/Bulkheaded (atmospheric)
Elevated (atmospheric)
Hydropneumatic/Pressure
Other:
Section C. Time Frame for Project Implementation (approximate dates)
Date tank to be taken out of service:
Date tank is to be back in service:
rev 06.13.2012
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Storage Tank Interior Painting Project Application
Section D. Operation of System During Implementation of Project
The project may require a temporary change in system operation as a result of the tank being taken out of
service. If applicable, provide a brief description of these changes in an attached document. If temporary
storage, piping, etc. is to be provided, these components must be included with this application for review, and
approval must be obtained from the DPH prior to implementation. [RCSA Section 19-13-B102(d)(2)]
Section E. Interior Surface Paint or Lining
The DPH accepts the use of an interior paint or lining which is certified to ANSI/NSF Standard 61. ANSI/NSF
Standard 61 is a national industry standard pertaining to the certification of drinking water system components.
There are third party accredited testing laboratories including, but not limited to, NSF (www.nsf.org), UL
(www.ul.com), and WQA (www.wqa.org) which certify drinking water system components to this standard.
Name of product used for interior surface paint/lining:
Manufacturer:
* Provide a copy of the ANSI/NSF Standard 61 certification/listing for the proposed paint/lining to be used on the
interior of the tank(s).
Section F. Modified or Replaced Tank Components (Atmospheric Tanks):
* If the project includes the modification or replacement of vents, overflows, access hatches, drains, etc. plans
and specifications and/or manufacturers’ cut sheets for these components must be provided so that they can be
assessed for compliance. [RCSA Section 19-13-B102(f)(5)(A)]
Check off any of the following items that will be modified or replaced and complete information as applicable:
Vent(s): Type of vent(s):
dome;
inverted J-shaped;
mushroom; No. of vents:
protected and screened; mesh size of screen:
Overflow:
protected and screened; mesh size of screen:
tight fitting flap valve;
duck-bill elastomeric check valve;
air-gapped above grade or above receiving
structure, and if not, describe:
Access hatches:
in top of tank,
hatch opening has raised curb frame and overlapping cover preventing
precipitation from entering into the tank,
hatch frame/cover has continuous gasket;
lock provided;
in top of tank, circular with gasket and bolted cover
Tank drain: discharge location/outlet structure:
Footing drain: discharge location:
Emergency fill pipe:
with locked cap or equivalent
Inlet pipe and outlet pipe:
common; or
separate;
with isolation valves
Sample tap(s), smooth nose and free of obstructions; and locations
inlet pipe;
outlet pipe
Access ladder:
with security protection, description:
Internal mixing/circulation system (identify type):
Perimeter fencing;
Locked access gate
rev 06.13.2012
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Storage Tank Interior Painting Project Application
Section G. Disinfection/Testing
A tank must be effectively disinfected prior to placing into service. [RCSA, Section 19-13-B47]
Method of disinfection to be implemented:
Tests must be conducted on a sample from the water stored in tank after disinfection and prior to placing the tank
into service for chlorine residual, total coliform, physical parameters and organic chemicals (aka VOCs).
Section H. Certification
This application must be signed by the PWS administrative official, his/her authorized representative, or certified
operator of the PWS.
I hereby certify that I have examined the information contained in this application as submitted to the DPH and
have determined it to be accurate to the best of my knowledge:
Signature:
Date Signed:
Name (Print):
Telephone #:
Title and Relationship to PWS:
rev 06.13.2012
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Storage Tank Interior Painting Project Application
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