Form ECY070-522 "Fuel Request for Underground Storage Tanks (Usts)" - Washington

What Is Form ECY070-522?

This is a legal form that was released by the Washington State Department of Ecology - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Washington State Department of Ecology;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ECY070-522 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

ADVERTISEMENT
ADVERTISEMENT

Download Form ECY070-522 "Fuel Request for Underground Storage Tanks (Usts)" - Washington

Download PDF

Fill PDF online

Rate (4.3 / 5) 61 votes
F
R
UEL
EQUEST
UST ID #: __________
U
S
T
(UST
)
FOR
NDERGROUND
TORAGE
ANKS
S
County: __________
This form is used to request a one-time fuel drop for testing purposes only.
Instructions are on the back page.
I. UST F
II. O
/O
I
ACILITY
WNER
PERATOR
NFORMATION
Facility Compliance Tag #:
Owner/Operator Name:
UST ID #:
Business Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Site Phone:
Email:
III. T
I
ANK
NFORMATION
(for tanks needing a one-time fuel drop)
T
ID
T
P
-T
* R
(P
/F
)
T
C
S
S
ANK
ANK
RE
EST
ESULT
ASS
AIL
ANK
APACITY
UBSTANCE TO BE
TORED
IV. C
HECKLIST
Proof of tank insurance or financial responsibility is attached.
UST equipment (see instructions) is functioning per manufacturer specifications and UST regulations. Proof is attached.
Tank(s) # _________________________ PASSED the pre-test* and a FUEL DROP is requested. Test results attached.
Tank(s) # _________________________ FAILED the pre-test* and Ecology was notified within 24 hours. Test results attached.
V. S
P
I
ERVICE
ROVIDER
NFORMATION
Company Name:
Provider Name:
Address:
Certification Type:
City:
State:
Zip:
Cert. Number:
Exp. Date:
Provider Cell Phone:
Provider Email:
Service Provider Signature:
Date:
VI. F
D
I
UEL
ISTRIBUTOR
NFORMATION
Fuel Distributor Co.:
Phone:
Email:
Prior to delivering fuel, the distributor must verify this form includes an Ecology signature (within the last 30 days) and a PASS
result is next to each tank receiving fuel.
VII. O
/O
S
WNER
PERATOR
IGNATURE
Signature acknowledges UST(s) comply with WAC 173-360A.
Date
Signature of Tank Owner or Authorized Representative
Print or Type Name
Owner/operator must fill out the top section and submit to Ecology for signature.
VIII. E
S
COLOGY
IGNATURE
(required to receive one-time fuel drop)
UST Inspector:
Phone:
Email:
Inspector Signature:
Date:
FUEL REQUEST EXPIRES 30 DAYS AFTER THE DATE SIGNED BY INSPECTOR.
To request materials in a format for the visually impaired, call Ecology at 360-407-7170, Relay Service 711, or TTY 877-833-6341
ECY 070-522 (Revised October 2018)
F
R
UEL
EQUEST
UST ID #: __________
U
S
T
(UST
)
FOR
NDERGROUND
TORAGE
ANKS
S
County: __________
This form is used to request a one-time fuel drop for testing purposes only.
Instructions are on the back page.
I. UST F
II. O
/O
I
ACILITY
WNER
PERATOR
NFORMATION
Facility Compliance Tag #:
Owner/Operator Name:
UST ID #:
Business Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Site Phone:
Email:
III. T
I
ANK
NFORMATION
(for tanks needing a one-time fuel drop)
T
ID
T
P
-T
* R
(P
/F
)
T
C
S
S
ANK
ANK
RE
EST
ESULT
ASS
AIL
ANK
APACITY
UBSTANCE TO BE
TORED
IV. C
HECKLIST
Proof of tank insurance or financial responsibility is attached.
UST equipment (see instructions) is functioning per manufacturer specifications and UST regulations. Proof is attached.
Tank(s) # _________________________ PASSED the pre-test* and a FUEL DROP is requested. Test results attached.
Tank(s) # _________________________ FAILED the pre-test* and Ecology was notified within 24 hours. Test results attached.
V. S
P
I
ERVICE
ROVIDER
NFORMATION
Company Name:
Provider Name:
Address:
Certification Type:
City:
State:
Zip:
Cert. Number:
Exp. Date:
Provider Cell Phone:
Provider Email:
Service Provider Signature:
Date:
VI. F
D
I
UEL
ISTRIBUTOR
NFORMATION
Fuel Distributor Co.:
Phone:
Email:
Prior to delivering fuel, the distributor must verify this form includes an Ecology signature (within the last 30 days) and a PASS
result is next to each tank receiving fuel.
VII. O
/O
S
WNER
PERATOR
IGNATURE
Signature acknowledges UST(s) comply with WAC 173-360A.
Date
Signature of Tank Owner or Authorized Representative
Print or Type Name
Owner/operator must fill out the top section and submit to Ecology for signature.
VIII. E
S
COLOGY
IGNATURE
(required to receive one-time fuel drop)
UST Inspector:
Phone:
Email:
Inspector Signature:
Date:
FUEL REQUEST EXPIRES 30 DAYS AFTER THE DATE SIGNED BY INSPECTOR.
To request materials in a format for the visually impaired, call Ecology at 360-407-7170, Relay Service 711, or TTY 877-833-6341
ECY 070-522 (Revised October 2018)
I
NSTRUCTIONS
This Fuel Request form must be submitted with passing results of a pre-test* in order to receive approval for a fuel
delivery to an empty tank, since some third-party certified tightness test** methods require fuel to conduct the test. Once
the Fuel Request is approved, a third-party certified tightness test** may be conducted as a requirement to bring a
temporarily closed tank back into operation. If a tightness test** method allows for testing on an empty tank, this form is
not required. To be approved for a one-time fuel delivery, submit this completed form along with supporting
documentation to the Ecology region where the UST facility is located (see region location information below).
I./II.
Site and Owner/Operator Information: If the UST ID number and/or the facility compliance tag number are
unknown, call an Ecology office listed below.
Tank Information: Use the same Tank IDs that are listed on the facility’s Business License, ensure the tank fees
III.
are current and paid. Fill out the results of the pre-test*.
IV.
Checklist: Attach proof of tank insurance (or financial responsibility), proof the UST system is operating
properly, including leak detection equipment, corrosion protection (if applicable), and the results of the pre-test*.
If any tank fails the pre-test*, Ecology must be notified within 24 hours and no fuel may be delivered to that tank.
V.
Service Provider Information: By signing this section, the ICC-certified tester certifies testing was conducted in
accordance with the manufacturer’s requirements and the results have been provided to the owner/operator.
VI.
Fuel Distributor Information: The fuel distributor must verify this form includes an Ecology signature and
passing results for each tank that will be receiving fuel for testing. The distributor may drop a minimum amount
of fuel for testing purposes within 30 days of the Ecology signature date.
VII.
Owner/Operator Signature: By signing this section, the owner/operator attests the UST system(s) are in
compliance with the UST regulations. The owner/operator is responsible for attaching the required documents
listed in the instructions for Section IV.
VIII.
Ecology Signature: After review of the submitted documents, Ecology will fill out Section VIII and return this
form to the owner/operator address listed in Section II. Ecology recommends scheduling the testing as soon as
possible after a delivery to reduce the risk of a release to the environment.
*Pre-test – Prior to receiving approval for a fuel delivery, you may be required to test your tank for a leak using a
pressure decay test, interstice pressure test, or other empty tank method. Check with your tank service provider to
determine the best pre-test method for your tank.
**Tightness test – This test must be third-party certified and conducted by an ICC-certified Tank Tightness Tester.
Some test methods cannot be conducted on empty tanks and piping.
Prior to receiving additional fuel deliveries, an
Operational Status Notice
with passing tank tightness test results must be
submitted to Ecology within 30 days of bringing tanks back into service. After Ecology review, a new facility compliance
tag will be issued, if applicable.
Further questions? Please contact your regional office below and ask for a tank inspector to assist you.
Regional Office
Mailing Address
Counties Served
1250 W. Alder St.
Central (509) 575-2490
Benton, Chelan, Douglas, Kittitas, Klickitat, Okanogan, Yakima
Union Gap, WA 98903
4601 N. Monroe
Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant, Lincoln,
Eastern (509) 329-3400
Spokane, WA 99205
Pend Oreille, Spokane, Stevens, Walla Walla, Whitman
PO Box 47600
HQ (360) 407-7170
Federal facilities in Western Washington
Olympia, WA 98504-7600
th
3190 160
Ave. SE
Northwest (425) 649-7000
Island, King, Kitsap, San Juan, Skagit, Snohomish, Whatcom
Bellevue, WA 98008-5452
PO Box 47775
Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Lewis, Mason,
Southwest (360) 407-6300
Olympia, WA 98504-7775
Pacific, Pierce, Skamania, Thurston, Wahkiakum
To request materials in a format for the visually impaired, call Ecology at 360-407-7170, Relay Service 711, or TTY 877-833-6341
ECY 070-522 (Revised October 2018)
To request materials in a format for the visually impaired, call Ecology at 360-407-7170, Relay Service 711, or TTY 877-833-6341
ECY 070-522 (Revised October 2018)
Page of 3