Storage Tank Pollution – Quick Quote Application

Facility Name

Facility ID

Facility Address

Contact Name(Required)

First Last

Contact Phone

Contact Fax

Federal Employer Identification Number (FEIN)

Effective Date

Current Issuer

Brand

UST/AST

Install Date

Capacity (gal.)

Tank Construction

Overfill/ Spill Protection

Tank Leak Detection

AST Diking & Base Construction

Piping Construction Material

Piping Leak Detection

CONTENTS
A. Unleaded Gasoline
B. Gasohol
C. Diesel
D. Kerosene
E. Waste Oil/ Used Oil
F. Fuel Oil
G. Generic Gasoline
H. Pesticide
I. Ammonia compound
J. Chlorine compound
K. Haz. Substance (CERCLA)
L. Mineral Acids
M. Grades 5&6 bunker 'C' oils
N. Petroleum-base additive(E85) O. Misc.
petroleum-base P. Heating Oil
Q. Other, please indentify

TANK CONSTRUCTION
A. Steel
B. Fiberglass
C. FRP Clad Steel
D. Concrete
E. Polyethylene
F. Other EPA/DEP Approved G. Cathodic Protection Sacrificial Anode
H. Cathodic Protection - Impressed Current
I. Double Walled(DW) - Single Material
J. Double Walled (DW)- Dual Material
K. (DW)Synthetic Liner in Tank Construction
L. (DW)Pipeless UST with Secondary Containment
M. Internal Lining STI. STI-P3

OVERFILL/SPILL PROTECTION
A. Ball Check Valve
B. Spill Containment Bucket
C. Flow Shut-off
D. Tight Fill
E. Level Gauges, High Level Alarms
F. Other EPA/DEP Approved Protection Method

PIPING CONTRUCTION MATERIAL
A. Steel
B. Fiberglass
C. Double walled
D. Approved Synthetic Material
E. Other EPA/DEP Approved Piping Material
F. External Protective Coating G. C/P with sacrificial anode or impressed current

PIPING LEAK DETECTION
Piping Leak Detection A. Electronic Line Leak Detector with Flow Shutoff
B. Interstitial Monitoring – Piping Filter
C. External Monitoring
D. Mechanical Line Leak Detector
E. Interstitial Monitoring of double wall piping
F. Suction Pump Check Valve

TANK LEAK DETECTION
A. Groundwater Monitoring Wells
B. Interstitial Monitoring
C. Vapor Monitoring Wells
D. Visual Inspections of AST Systems
E. Other EPA/DEP Approved
F. SPCC Plan - AST
G. Interstitial Space -Double Walled Tank H. Manual Tank Gauging - UST
I. Statistical Inventory Reconciliation - (SIR)(USTs)
J. Automatic Tank Gauging System (USTs)
K. Interstitial Monitoring of AST tank bottom
L. Annual Tightness Test with Inventory - double wall piping (USTs)

AST DIKING & BASE CONSTRUCTION
A. Concrete, Synthetic Material, clays
B. Other EPA/DEP approved secondary containment system
C. Dirt/Earth

1. Do you operate any tanks not registered with the state and are subject to registration under the Natural Resources Conservation Commission?

Yes

2. Are there any tanks within 10 miles from any coast?

Yes

3. Any hazardous, toxic or regulated substances stored at any site for which this application for insurance is being made other than Gasoline, Diesel, Motor Oil or Kerosene?

Yes

4. Do you have more than 2 years of owning or operating UST exposures?

Yes

5. Have there been or are there any fines, penalties or legal actions currently pending against you including State, Federal or any other compliance order an any pollution incident?

Yes

6. Are all tanks listed in this application in compliance with regulations set forth by the United States EPA and any state agency?

Yes

7. Has any officer, owner or partner of the company been convicted of a felony?

Yes

8. Are you aware of any circumstances which could give rise to a pollution incident?

Yes

9. Have you had any insurance for third-party pollution liability declined, cancelled or non-renewed?

Yes

10. Do you have any tanks that were not previously insured, excluding newly installed tanks?

Yes

11. Do you own or operate Skid Tanks?

Yes

12. Are there, or will there be, any tanks in which you will not be the owner or operator?

Yes

13. Do you own or operate any Bulk Storage Tanks?

Yes

STORAGE TANK QUICK QUOTE APPLICATION