TankReconditioningFormWord

Application for Water Tank Reconditioning Plan Approval
($50 Review Fee Required)

North Carolina Department of Environmental Quality
Division of Water Resources
Public Water Supply Section

_________________________________________
Water System Name

____________________________
Water System Number

Name and Location (Street Address) of Tank:

Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301
Phone: [phone]
Mooresville Regional Office
610 E. Center Ave., Ste. 301
Mooresville, NC 28115
Phone: [phone]
Raleigh Regional Office
3800 Barrett Drive
1628 Mail Service Center
Raleigh, NC 27699-1628
Phone: [phone]





Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405-3845
Phone: [phone]
Winston-Salem Regional Office
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Phone: [phone]



**Provide this notice to your Regional Office 30 days prior to commencement of work. Once 30 days have passed, Approval of Application is automatically granted unless written comments
have been received from Public Water Supply.

For Agency Use Only: Regional Office shall FAX this application (4 pages) to central office for tracking upon initial receipt and page 1 of 4 when ready for Final Approval:

_____/_____/_____ Date form received by Regional Office
_____/_____/_____ $50 Fee Acknowledged by Regional Office
_____/_____/_____ Plan Approval Date
_____/_____/_____ Date Engineer’s Certification with disinfection results received
_____/_____/_____ Date to issue Final Approval

To: Division of Water Resources
Department of Environmental Quality
Application for Water Tank Reconditioning Plan Approval

The
(name of board, or council, authorized official and title, or owner)

of
(name of city, town, corporation, sanitary district, water company or other)

in the County of _______________________________, State of North Carolina is authorized by law to act for

the said
(name of city, town, corporation, sanitary district, water company or other)
and to expend its funds for reconditioning of the water tank described below:

Name and Location (Street Address) of Tank:

Type of Tank: Ground / Elevated / Standpipe / Other ______________________________ (Circle One)

Size of Tank (Working Volume):

Year Constructed: __________________________ Year of Last Reconditioning:

Number of Tanks in System: __________

If one tank, method for maintaining system pressure during recondition:

Water System Interconnections (Public Water System Name):

Description of Proposed Reconditioning:

Method of Disinfection: AWWA Method #2 OR 15A NCAC 18C .1003 (circle one)

Laboratory
Laboratory Providing Service: _________________________________________Certification #:

Microbiological Analysis - Samples to be collected by: Owner / Contractor / Other ____________________ (circle one)

Tank to be taken out of service on (date):

Tank returned to service on (projected date):

Remarks:

Specification of Materials: --- (Person Executing Application-Initials _________)

Tank interior and exterior surface are to be prepared in accordance with one or more of SSPC (Steel Structures Painting Manual) surface preparation methods. Painting application must
be in accordance with SSPC specifications (prime, stripe, intermediate and finished coats). Interior surface coatings material must be in the Certified Listings of ANSI/NSF Standard
61 and be applied in accordance with manufacturer’s recommendations and guidelines.

Paint Removal and
Reapplication of Coatings: --- (Person Executing Application-Initials _________)

The Air Quality Division should be contacted for a ruling on the necessity of the issuance of a permit to cover the preparation of the exterior of the tanks. The following procedure
should be used:

a. The tank owner should notify the Regional Office, Air Quality Division, in writing of the intent to sandblast at least five (5) working days prior to the commencement of the project.

b. The notification should contain, as a minimum:

i The name, address, telephone number and contact person for the tank owner.

ii The name, address, telephone number and contact person for the contractor.

iii Dates of sandblasting or paint removal.

iv Lead content, if any, of paint to be removed (analysis required).

v Measures to be taken to minimize off-premises impact of particulates and lead.

vi An area diagram showing the nearest residences within 1,000 feet.

The contractor should be encouraged to utilize measures such as wet blasting, shrouding, chipping, etc. such
that impacts on nearby residents and the environment are minimal.

The tank owner must forward a copy of this application to: Division of Public Health, Health and Hazard Control Unit, 1912 Mail Service Center, Raleigh, NC 27699-1912, phone [phone].

Waste Removal: --- (Person Executing Application-Initials _________)

All debris generated during the removal of the existing paints must be handled properly. If the paint is composed of RCRA metals, the contractor shall furnish the engineer with a certified
test report showing Toxicity Characteristic Leaching Procedure (TCLP) results for a representative random sample taken from the debris. Should any result exceed the EPA maximum limit
the owner shall have ninety days to dispose of the waste in accordance with the regulations provided by North Carolina's Division of Waste Management. The procedure for waste disposal
and obtaining the Provisional Number is outlined as follows:

Any waste may be separated into hazardous and non-hazardous portions, e.g. the lead may be separated from the abrasive but the lead cannot be diluted to render it non-hazardous.

To apply for a Provisional ID Number, the contractor handling the waste will submit a typed copy to: Administrative Assistant, Division of Waste Management, 1646 Mail Service Center,
Raleigh 27699-1646, North Carolina 27611-7687 or faxed to [phone] extension 209. Assistance may be obtained from the Division of Waste Management at [phone].

After the application is approved, a number will be issued over the telephone and a follow-up letter mailed to the contractor.

The date issued will be the effective date.

The number is good for ninety days and only for the waste indicated. However, time extensions may be granted for unusual, unforeseen circumstances. A written request is required.

A copy of the manifest signed by the transporter and disposer will be sent to the Division of Waste Management at the above address within 120 days of the effective date.

$50 Review Fee: --- Check or money order payable to DEQ-Public Water Supply Section
(Person Executing Application-Initials _________)

Engineer’s Report & Water System Management Plan:: Not Applicable for tank reconditioning.

Identification of Responsible Persons:

Professional Engineer (providing responsible supervision and certification)

Name _________________________________________________________________________NC PE #
Address

Responsible person for forwarding
Engineer’s Certification to Regional Office:

Distribution
Operator in Responsible Charge (distribution) _______________________________ Certificate #:

Final Inspection: (name & company affiliation) __________________________________________________________

Responsible person for forwarding
Disinfection & Microbiological
Results To Regional Office:

Contractor Information:
Contractor: ___________________________________Contact Person:

Mailing Address:

Phone: ________________________________ Fax:

Notify, as appropriate:
Systems interconnected with
Impacted Customers (Include neighbors adjacent to the tank site as needed)
Local County Health Department
Emergency Responders

Final Approval:

1. Tank will not be returned to service until an Engineer’s Certification (stating that all reconditioning and disinfection has been completed in accordance with the requirements of
this application and certify that the tank is ready and suitable to return to service) and disinfection results have been received by the appropriate Public Water Supply Regional Office
and Final Approval has been issued by the Public Water Supply Section’s Technical Services Branch.

2. The system has an Operation and Maintenance Plan and Emergency Management Plan as required by Rule .0307 and a certified operator as required by Section .1300.

__________________________________________________ _________________________
Signature of Owner, Manager, Mayor or Chairman Date

____________________________________________________________
Type or Print Name Signed Above

_______________________________________ _____________________________ __________ _____________
Street or Box Number City State Zip Code

(Person executing application must initial as indicated on page 3 of 4)