underground piping replacement form - lethbridge.ca · site number: facility address: legal land...
TRANSCRIPT
Site Number:
Facility Address:
Legal Land Description: (Lot, Block, Plan)
Facility Name:
Name:
Contact Person:
a) Company Name:
1. Tank Contractor:
Bare Steel Flexible Plastic
Lethbridge Fire Prevention Bureau 207 4 Avenue South, Lethbridge, Alberta T1J 0M8
Ph: 403-320-3811, Fax: 403-327-3511 Email: [email protected]
Underground Piping Replacement Form This form is intended for use at facilities where an underground piping system has been replaced.
SECTION 1: FACILITY INFORMATION
SECTION 2: PETROLEUM STORAGE TANK OWNER INFORMATION
Address:
SECTION 3: PIPING SYSTEM INFORMATION
b) Foreman's Name:
2. Date Work Completed:
3. Piping Material: (check all that apply) Galvanized Steel Fiberglass
Other (Specify):
4. Piping Secondary Containment: (check all that apply)
Double Walled Pipe None Pipe Trench Liner Other (Specify):
5. Steel Piping Cathodic Corrosion Protection: (check all that apply)
Sacrificial Anodes Impressed Current
6. Type of Pumping System: (check all that apply)
Suction Submersible Turbine(Pressure)
7. Line Leak Detection Installed: (check all that apply)
Single, Vertical Check Valve (Suction) Line Leak Detector (Pressure Systems)Monitoring WellsInterstitial Monitoring of Double Walled PipeOther (Specify):
Phone Number:
Phone Number:
The personal information collected on this form is within Section 33 of the Freedom of Information and Protection of Privacy Act. It is used for the purpose of Underground Piping Replacement and will only be disclosed to the Fire Prevention Bureau. If you have any questions please contact the
Fire Prevention office at 403-320-3811 or e-mail to [email protected].
SECTION 4:
1. Comments:
2. Information Completed By:
3. I hereby confirm that the information provided on this form is complete and accurate to the best of my knowledge.
Approved By (Owner of Tanks)
Date:
Office Use Only
Reviewed By: SC #:
Date Submitted:
Signature
ONCE COMPLETED: PLEASE SELECT "SUBMIT BY EMAIL" BUTTON AT TOP OF FORM OR "PRINT FORM" BUTTON AND FAX A COPY TO THE FIRE PREVENTION BUREAU
Yes NoApproved:
Signature or Name