HomeMy WebLinkAbout0000137-Storage Tank (install 2 tanks) DATE / 91 A,-CI � /q6
APPLICATION FOR FLAMMABLE LIQUID STORAGE TANK PERMIT
Name of Owner CJ[NAJEgACsd aum
Address of Owner / 2-2-1 -/:0 f
Application is hereby made to place 2- tank(s) for the
storage of 5 (n.1.E__..' on the property known
as `02 a / Pe cs
Size of tank (s) 1 o, (3 � gallons .
Tank (s) to be placed (below) 4-&bovc) ground level.
Location
•
(Width of Lot) M _�
Zone
Fe ,26
0
a 2j5
4-, Z 1
Fire Prevention Bureau Approval
d Q
A
The undersigned agrees that the above tank(s) will be placed in
accordance with Section 13 -17 to 13 -23 of the Municipal Code of the
City of Oshkosh.
Signed,
Permit Number 13-7
Permit Issued G
- 60 -
CDD /10 /PH
DEPT. OF INDUSTRY, APPLICATION FOR INSTALLATION SAFETY & BUILDING DIV.
LABOR AND OF FLAMMABLE LIQUID TANKS P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
Application is hereby made to the Department of Industry, Labor and Human Relations for Permission to; (Check all applicable)
® install tanks ❑ install tanks with self- service ❑ install tanks with key- card -code.
❑ revise a plan ❑ convert full service to self - service or key- card - code -only.
in accordance with the following detailed statement and attached plans subject to the orders of the Department of Industry, Labor and Human Relations,
The installation, in all other respects, will comply with applicable provisions of Chapter ILHR 10 of the Wisconsin Administrative Code, (FLAMMABLE
AND COMBUSTIBLE LIQUIDS)
DIRECTIONS:
Submit one copy of this form and three copies of the plot plan, along with the required fee to the nearest approval authority listed on
the back of this form.
Each plan must show (1) property lines, (2) buildings, (3) tanks, (4) Toad and unload racks OR pump islands, (5) streets and highways
(6) streams and bodies of water within 150 feet of tanks, (7) vehicular routes, (8) distances and (9) wells.
Two copies of the plans and a letter of conditional approval will be returned to you after approval.
A final inspection of the site must be performed by the local file inspector before the tank is covered or before product is put in the
tank.
LOCATION WHERE TANK(S) WILL BE INSTALLED
OWNER /OPERATOR NAME OF ESTABLISHMENT
Winnebago County _ Winnebago County Highway Commission
STREET ADDRESS CITY COUNTY STATE ZIP CODE
1221 Knapp St., P.O. Box 2764 Oshkosh Wi nrliebago WI 54901 -2764
TANK SPECIFICATIONS: (Each Tank)
Horizontal Vertical nder ground Capacity Length Diameter Contents New Used Gaups
ground
1 X X 10.000 17' 3" 10' Regular X i"
2 X X 15,000 25' 7" 10' No -Lead X 5/16"
3
4
IS PUMP MOTOR AYES ONO ARE PUMP SWITCHES CIYES ONO ARE BONDS AND GROUNDING
JYES ONO
EXPLOSION PROOF? EXPLOSION PROOF? PROVIDED AT LOAD /UNLOAD RACKS?
UNDERGROUND TANKS:
DESCRIBE DISTANCE BURIED: SIZE OF SIZE AND HEIGHT MOM/ 2 " — 1 Z' above rade
Top 3' below grade FILL PIPE: 4" OF VENT: 15,000 3" X 12' above T rade
IS THE TANK?JSTEEL ❑FIBERGLASS ❑OTHER (specify)- I UL Approved: DYES ONO
CORROSION PROTECTION (Steel Tanks)
CAPACITY HOW MANY SIZE OF SPECIFY: DIELECTRIC UNION NAME OF APPROVED COATING
OF TANK ANODES? ANODES OR ISOLATION BUSHING
1 10,000 4 each 17 -LBS ❑DU Me STIP - 3
2 15,000 4 each 17 -LBS ❑DU (RIB STIP - 3
3 ❑DU ❑IB
4 ❑DU ❑IB
CATHODIC PROTECTION OF L�SYES ONO COLLECTION SUMP ON �L7YES ONO
ABOVE GROUND TANKS UNDERGROUND PIPING? PLOT PLAN
REGULAR VENT PRESSURE /VACUUM MAKE: NUMBER: SIZE:
EMERGENCY RELIEF VENT MAKE: NUMBER: SIZE:
MAKE; NUMBER: SIZE:
EMERGENCY INTERNAL VENT
DESCRIBE SUPPORTS /FOUNDATION DIKING PROVIDED SPECIFY DISTANCE BETWEEN TANKS
OYES ONO
SBD -9 (R. 02/85) SEE REVERSE SIDE
- 61 -
VERTICLE TANKS — LIST THICKNESS OF METAL:
BOTTOM: TOP: SHELL -LOWER REMAINDER: BOTTOM: TOP: SHELL -LOWER REMAINDER:
COURSE: COURSE:
1. 3,
BOTTOM: TOP: SHELL -LOWER REMAINDER: BOTTOM: TOP: SHELL -LOWER REMAINDER:
COURSE: COURSE:
2. 4.
FEES — (IND -69)
• NO. OF
INSTALLATION TANKS COST SUB TOTAL
Plan Examination -5,000 to 100,000 gallon capacity 2 X $32.00 = $ 64•00
Site Inspection -5,000 to 100,000 gallon capacity 2 X $43.00 = $ 86.00
SELF SERVICE OR KEY- CARD -CODE
Plan Examination • $22.00 = $
Site Inspection $43.00 = $
REVISION OF PREVIOUSLY APPROVED PLAN $22.00 = $,
GROUND WATER SURCHARGE (Stat. 101.14(5)) = $, 100.00
TOTAL FEE =$ 260.00
WHERE SHOULD PLAN APPROVALS BE SENT?
NAME
DOWNER/OPERATOR [INSTALLER
Winnebago County Highway Commission
STREET ADDRESS CITY, STATE, ZIP CODE
1221 Knapp St., P.O. Box 2764 Oshkosh, WI 54903 -2764
CERTI FICATION
I CERTIFY BY SIGNATURE THAT PROVISIONS OF ILHR 10,
TO INCLUDE COLOR CODING OF FILL PIPES, AND OTHER REQUIREMENTS,
LISTED OR NOT LISTED HEREON, WILL BE COMPLIED WITH. Also, no tank
will be installed within 100' of a well (DNR Rule).
•
•
,,,,� :,I Commissioner 3 -31 -86 (414) 424 -0025
SIGNATU E a DATE PHONE NUMBER
RETURN THIS APPLICATION WITH APPROPRIATE FEE(S) TO THE AREA CLOSEST TO YOU:
SAFETY & BUILDING DIVISION SAFETY & BUILDINGS DIVISION SAFETY & BUILDINGS DIVISION SAFETY & BUILDINGS DIVISION
FIRE PREVENTION WAUKESHA OFFICE GREEN BAY OFFICE CHIPPEWA FALLS OFFICE
POST OFFICE BOX 7969 FIRE PREVENTION COORD. FIRE PREVENTION COORD. FIRE PREVENTION COORD.
201 E . WASHINGTON AVENUE 1570 E. MORELAND BLVD. 2331 SAN LUIS PLACE 13 E. SPRUCE ST.
MADISON, WI 53707 WAUKESHA. WI 53186 GREEN BAY, WI 54304 CHIPPEWA FALLS, WI 54729
(606) 2664076 (414) 5215444 (414) 4974006 (715) 723-1903
1 / ViNNEI�A"' COUiJTY
AREF 51
x z
oi l
0 0 - It
uML,:At ii6G G1 SF L
1 ' Lr.
0
DEPARTMENT
l J
LQ
Q-
R E. PL ra ( r-- tA li. tA T
ST TVIKe
0 x 25 EXI 0
IV 4ps p4% p
5 TO A A
f 90
7
H i G H vvAY
PL A
OF 0 Lo:
'�/ _ � � 1 � X-1
S TORA GE
3 UILD / Nc-
A
�J -4
J f
Z-
L
A VE.
(j
iN 7 &',E L F Tq
A VE .
0 5 8 (� S N
A VIE ,
d.
DRA,\\A/N BY.' M,C
DATE. 5110180