Form Center

2. Creating an account or logging in to Form Center is optional and is not required to submit this form.
4. I. FACILITY INFORMATION
6. Facility Name
8. Facility Street Address
10. City
11. State
12. Zip Code
14. Facility Mailing Address (if different)
16. City
17. State
18. Zip Code
20. Contact Person
21. Contact Phone Number
22. Contact Email
24. Tank Location Address
26. City
27. State
28. Zip Code
30. Qtr Section
31. Section
32. County
33. Number of aboveground tanks already at this location
35. Township
36. S. Range
37. Select one*

    1. E
    2. W
38. Number of undergound tanks already at this location
40. Are tanks to be taken out of service because of this new installation?
    -- Select One --YesNo
42. Does your abandonment or reuse of the aboveground tanks comply with NFPA 30?
    -- Select One --YesNo
44. Addition information (if needed)
46. Are tank(s) currently in use?
    -- Select One --YesNo
47. If yes, date installed:
    If yes, date installed:
49. Are tank(s) new installation and not yet in service?
    -- Select One --YesNo
50. Additional information (if needed)
52. Leak Detection (Check all that apply)

    1. Vapor Monitoring
    2. Ground Water Monitoring
    3. Visual Monitoring
    4. Interstitial Monitoring Double Wall
    5. N/A
53. Type of Usage

    1. Airport Fuels (80)
    2. Agriculture (81)
    3. Alcohol Fuel/Bio Diesel MFG Facilities (82)
    4. Private (KDOT/County Road Dept., Feed Lots) (83)
    5. Bulk Site (86)
    6. Service Station/Gas Station/Convenience Store (87)
    7. Attended/Unattended Keytrol or Cardtrol (87)
    8. Trucking Companies (88)
    9. Other
55. Hours of Operation
56. If other selected under "Type of Usage," enter type here:
60. II. TANK OWNER INFORMATION
62. Owner Name
64. Owner Address
66. City
67. County
68. State
69. Zip Code
71. Contact Person
72. Email Address
74. Phone Number
75. Fax Number
77. Owner Type

    1. Government
    2. Industrial/Business
    3. Farm
    4. Retail
    5. Other
79. If other selected for "Owner Type," enter type here:
83. III. CONTRACTOR/INSTALLER INFORMATION:
85. Contractor/Installer Name
86. Contact Person (if different)
88. Address
90. City
91. County
92. State
93. Zip Code
95. Phone Number
96. Fax Number
100. IV. TANK INFORMATION
102. If applying for multiple tanks, list tank site numbers for each answer in field.
     Example: Is your tank UL 142 compliant? Tank 1: Yes Tank 2: Yes
104. Is your tank UL 142 compliant?
105. Individual tank number (located on Data Plate)
106. Capacity in gallons
107. Tank dimension, length & width
109. Single Wall or Double Wall?
110. Is your tank fire resistive and complies with UL 2080 or an equivalent test procedure?
111. Type of product being stored in tank:
112. Classification of product being stored: Class I, II, III
114. Manufacturer of tank
115. Type of Dike Construction
116. Dike size: LxWxH
117. Dike capacity (in gallons) Must contain 110% of the largest tank
119. Emergency vent size
120. Atmospheric vent size
121. Orientation (Horizontal/Vertical)
122. Year installed
124. Age of tank
125. Corrosion protection (paint, etc.)
126. Does your electrical wiring comply with NFPA 70 (National Electric Code)?
128. All tanks shall be painted and display clear product identification in 3-inch (minimum) letters. The NFPA 704 MARKING SYSTEM may also be required, depending on product hazard classification, local requirements, or tank locations. A weather-proof sign with contact persons and emergency numbers will be posted on site with a minimum of 3-inch letters in plain view. (Keytrol or Cardtrol locations) If product stored is NOT a petroleum product but a flammable or combustible or hazardous substance, please provide CERCLA name or CAS registration number and the Material Safety Data Sheet. Attach a copy to application.
130. Attach supporting information in PDF format here.
134. V. OTHER TANK INFORMATION
136. Are you receiving Class I liquids from mainline pipelines or marine vessels?
     -- Select One --YesNo

     If yes, prevention of overfilling tanks is required per NFPA 30
138. 
140. Number of feet from the nearest building on same property
141. Number of feet from the nearest property line
142. Number of feet from the nearest residence
143. Number of feet from public street
145. Number of feet from tanks to transport unloading & bulk load out
146. Number of feet from dispensers from aboveground tanks
150. VI. RETAIL FACILITIES
152. 
154. For SI Units, 1 ft = 0.3 m; 1 gal = 3.8 L
156. Number of feet from the nearest building on same property
157. Number of feet from the nearest property line
158. Number of feet from the nearest residence
159. Number of feet from public street
161. Number of feet from tanks to transport unloading & bulk load out
162. Number of feet from dispensers from aboveground tanks
166. VII. PIPING INFORMATION
     All piping must comply with NFPA 30
168. Do your piping, valves and fitting comply with NFPA 30?
     -- Select One --YesNo
169. Is the piping aboveground?
     -- Select One --YesNo
171. Pipe Construction

     1. Alloy
     2. Steel
     3. Stainless Steel
     4. PVC
     5. Copper
     6. Galvanized
     7. Fiberglass
     8. Black Piping Coat
     9. No Piping Used
     10. Rubber Fuel Line
172. Is the piping underground?
     -- Select One --YesNo
174. Provide additional information (if needed)
178. VIII. DISPENSER INFORMATION
     All dispensers must comply with NFPA 30A
180. Do your dispensers comply with NFPA 30A?
     -- Select One --YesNo
181. Are emergency breakaway devices provided on all dispensing hoses?
     -- Select One --YesNo
182. Are all dispensers securely anchored, and do they have collision protection installed?
     -- Select One --YesNo
184. Provide additional information (if needed)
188. IX. STORAGE TANK BASE TYPES
190. Types

     1. Asphalt
     2. Cinder Block
     3. Concrete

     1. Concrete Vault
     2. Dirt Base with Liner
     3. Ground

     1. Metal Containment
     2. Steel
     3. Supports
194. X STORAGE TANK CONSTRUCTION
196. Types

     1. Aluminum
     2. Concrete

     1. Steel
     2. Double Wall Tank

     1. Fiberglass Chemical Tank
     2. ASME LP Gas Storage Tanks
200. XI. STORAGE TANK APPROVAL
202. Type

     1. API Approval Number
     2. ASME Tank LP Gas

     1. National Standard
     2. Underwriters Labs

     1. Other
204. If "Other," provide information:
208. XII. PLANS
     Plans should document the location of the tanks, lines, monitoring equipment, nearby structures, and property boundaries. Provide a separate detailed drawing of tank, piping, valves, and dispenser locations. Submit a complete application and plans to the Kansas Office of the State Fire Marshal for approval. A minimum of twenty (20) working days prior to the anticipated installation date must be allowed for sufficient time to review the plans. Once approval is completed, a copy will be forwarded to KDHE for registration. Please submit plans on sheets of paper no larger than 11x17. Drawings do not have to be to scale; however, they must detail the required information.
210. Electronic version of plans can be uploaded here
     Plans can also be mailed or delivered to: OSFM, 800 SW Jackson, Ste 104, Topeka, KS 66612.
214. XIII. APPLICANT'S CERTIFICATION
     I CERTIFY THAT THE INFORMATION ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND THAT ALL EQUIPMENT WILL BE INSTALLED IN COMPLIANCE WITH THE MANUFACTURER INSTALLATION REQUIREMENTS. THIS INSTALLATION WILL BE PERFORMED IN COMPLIANCE WITH ALL FEDERAL, STATE, AND LOCAL REGULATIONS.
Leave This Blank:


216. 1. Receive an email copy of this form.
217. Email address

     This field is not part of the form submission.

218. Submit Submit and Print

* indicates a required field