"Storage Tank Project Application Form" - Connecticut

Storage Tank Project Application Form 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 12, 2012;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
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Download "Storage Tank Project Application Form" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
STORAGE TANK PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for storage tank projects, 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 the design of a storage tank and identifies
applicable Regulations of Connecticut State Agencies (RCSA) or Connecticut General Statutes (CGS).
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 [ ]. If the project overall has multiple components
other than a storage tank (i.e. wells, treatment, pumps, etc.), additional applications may need to be
completed. Check off all items that apply.
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)
Standpipe (atmospheric)
Hydropneumatic/Pressure
Ground Level (atmospheric)
Other:
Buried/Bulkheaded (atmospheric)
Elevated (atmospheric)
rev 06.12.2012
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Storage Tank Project Application
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
STORAGE TANK PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for storage tank projects, 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 the design of a storage tank and identifies
applicable Regulations of Connecticut State Agencies (RCSA) or Connecticut General Statutes (CGS).
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 [ ]. If the project overall has multiple components
other than a storage tank (i.e. wells, treatment, pumps, etc.), additional applications may need to be
completed. Check off all items that apply.
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)
Standpipe (atmospheric)
Hydropneumatic/Pressure
Ground Level (atmospheric)
Other:
Buried/Bulkheaded (atmospheric)
Elevated (atmospheric)
rev 06.12.2012
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Storage Tank Project Application
Section C. Plans and Specifications
* 1. For any buried or partially buried tank, atmospheric or hydropneumatic, a scaled site plan needs to be
submitted to the DPH identifying: that there are no buried subsurface sewage disposal system components or
sanitary sewers within a 50 feet of the proposed tank; and that there are no watercourses, storm drains or other
sources of pollution (i.e. fuel tanks/lines, drywells, etc.) within a 25 feet of the proposed tank. [RCSA Section 19-
13-B102(f)(5)(B)] If the tank(s) is not to be buried nor partially buried, check off:
Not Applicable (NA)
* 2. Scaled project plan sheet(s) or accurate construction drawing(s)/schematic(s) of the proposed storage tank(s)
and its location relative to applicable existing facility components or proposed new system components needs to
be submitted to the DPH. As a minimum and as applicable, the following components should be shown and
labeled: storage tank, vent(s), overflow, access hatches and/or manways, drain pipe, water level indicating
means, inlet and outlet pipes, valves, sample tap, etc. Detailed drawings for an atmospheric tank’s vent, overflow
and hatches should be provided.
3. Copy of contract specifications and/or manufacturers’ specifications/cut sheets for major project components
identified for this project (i.e. tank, hatch, vent, etc.), should also be submitted.
4. A tank must be located above the level of a 100 year flood. [RCSA Section 19-13-B102(d)(1)(A)]
* Verification must be provided (FEMA map or other).
Section D. Sizing/Volumes and Materials
1. Atmospheric Tank(s) and Clearwells
Tank Dimensions (feet)
No. of tanks:
Cylindrical:
Gross volume (gal./tank):
Diameter:
Useable volume (gal./tank):
Length/Height:
Material of tank:
welded steel;
bolted steel
Rectangular:
Length:
fiberglass;
polyethylene;
concrete;
other:
Width:
Height::
Identify pump type to supply/operate in conjunction with
tank:
well(s)
booster pump(s)
VFD
* Calculations used for sizing of tank(s) should be provided.
2. Hydropneumatic/Pressure Tank(s)
Material of tank:
steel;
fiberglass;
No. of tanks:
other:
Gross volume (gal./tank):
Identify pump type to supply/operate in conjunction with
Type:
std./conventional
bladder/diaphragm
tank:
well(s)
booster pump(s)
VFD
Flow rate (gpm) used for sizing of tank(s):
* Calculations used for sizing of tank(s) should be provided.
rev 06.12.2012
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Storage Tank Project Application
Section D. Sizing/Volumes and Materials (continued)
3. Interior 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 ANSI/NSF Standard
61. Glass fused steel or polyethylene atmospheric tanks or bladder/diaphragm pressure tanks, polyethylene or
other type tanks may be certified under a different standard.
Name of product used for interior surface paint/lining:
Manufacturer:
* Provide a copy of the ANSI/NSF Standard certification/listing for the proposed paint/lining to be used on the
interior of the tank(s) or for the tank.
Section E. Hydropneumatic Tank(s) Components/Appurtenances
Check off any of the following items that exist or will be provided in conjunction with the tank(s):
Pressure gauge
Drain/blowoff for each tank
Pressure relief valve
Inlet pipe and outlet pipe:
common;
separate;
Pressure switch
with isolation valve(s)
Proposed pressure settings for operation of well(s) or
Valves/controls for automatic addition of air
booster pump discharging to pressure tank:
Air compressor for adding air;
oil-less
Start/on (psi):
Water level sight tube
Stop/off (psi):
Section F. Atmospheric Tank(s) Components/Appurtenances
Check off any of the following items that exist or will be provided in conjunction with the tank(s):
Vent(s) [RCSA Section 19-13-B102(f)(5)(A)]:
Type of vent(s):
dome;
inverted J-shaped;
mushroom; No. of vents:
protected and screened; mesh size of screen:
Overflow [RCSA Section 19-13-B102(f)(5)(A)]:
protected and screened and mesh size of screen:
tight fitting flap valve;
duck-bill elastomeric check valve;
air-gapped above grade or above a
receiving structure, and if not, describe:
Access hatches and manways [RCSA Section 19-13-B102(f)(5)(A)]:
hatch 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;
in face of tank;
in sideshell
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
rev 06.12.2012
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Storage Tank Project Application
Section F. Atmospheric Tank(s) Components/Appurtenances (continued)
Access ladder:
with security protection, description:
Internal mixing/circulation system: type:
Perimeter fencing;
Locked access gate
Section G. Operating Water Level Equipment/Controls and Alarms (atmospheric tanks)
Check off any of the following items that exist or will be provided in conjunction with the tank(s):
Water level measuring:
translucent sidewall gal. incremented;
pressure gauge;
sight tube;
pressure sensor
Water level monitoring/recording:
chart recorder;
SCADA;
Alarms (identify feet from bottom of tank):
low water level:
high water level:
Alarm type:
audio
light
dialer
SCADA
Other controls associated with water level in tank::
well activation
booster pump shut-off on low tank level
Proposed tank operating levels (feet from bottom):
The high level identified below should correspond to the useable volume identified in Section D.1.
low
high
overflow
Section H. Contact Time (CT)
* If the tank is to be used whole or in part to achieve a required “CT” using chlorine, ozone or other disinfectant
chemical in accordance with Section 19-13-B102(e)(7)(M) of the RCSA, surface water treatment technique in
accordance with Section 19-13-B102(j)(3) of the RCSA, or 4-log inactivation of viruses in accordance with the
Ground Water Rule (GWR), an applicant must provide calculations used to assess CT. For a system which uses
groundwater sources [well(s)] and chlorine as a disinfectant, please refer to the DPH document GUIDELINES
FOR DETERMINING DISINFECTION “CT” WHEN USING CHLORINE FOR DISINFECTION OF
GROUNDWATER SOURCES OF SUPPLY and a separate DISINFECTION “CT” APPLICATION FOR A
GROUNDWATER USING CHLORINE FOR DISINFECTION. For CT requirements for surface water treatment
facilities, refer to Federal guidelines.
Section I. Disinfection/Testing
A tank must be effectively disinfected prior to placing into service. [Section 19-13-B47 of RCSA]
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 J. 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 06.12.2012
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Storage Tank Project Application
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