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: fireprevention@lethbridge.ca

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 fireprevention@lethbridge.ca.

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

1. Tank Contractor:

Lethbridge Fire Prevention Bureau

207 4 Avenue South, Lethbridge, Alberta T1J 0M8

Ph: 403-320-3811, Fax: 403-327-3511 

Email: fireprevention@lethbridge.ca

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

SECTION 3: PIPING SYSTEM INFORMATION

3. Piping Material: 

     (check all that apply)

4. Piping Secondary Containment: 

     (check all that apply)

5. Steel Piping Cathodic Corrosion Protection:

     (check all that apply)

6. Type of Pumping System:

     (check all that apply)

(Pressure)

7. Line Leak Detection Installed:

     (check all that apply)

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 fireprevention@lethbridge.ca.

SECTION 4:

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)

Office Use Only

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 

Approved:

Signature or Name

8.2.1.4029.1.523496.503679

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