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1. What is the name of the chemical to be stored? If the chemical will be a mixture of chemicals, list each component and the percent concentration (sum of concentrations should total 100%). Include trace chemicals and reaction gases or liquids.

Note: If only "trade names" are known, list the trade name, the name of the manufacturer, and a list of the individual components if known. Copies of MSDS(s) may be requested by CSI.

Chemical Name	Normal Concentration (Sum=100%)	Maximum Concentration*	Maximum Residence Time @ Max. Concentration

*Accounts for the possibility that a single component of a mixture could be dumped into the tank.
If the chemical is water (other than potable water or rain water) such as de-ionized, pure, ultra-pure, etc., show the concentration in ohm/cm.


2. Specific gravity range of the chemical or mixture:  to 


3. pH range of the chemical or mixture :  to 


4. Will tank be agitated: yes   no

Skip questions 5 and 6 if the answer is Yes.

5. Chemical oxygen demand: ppm   unknown
Normally required for leachate tanks or tanks with chemical mixtures.

6. Is burial depth less than or equal to 7 feet? yes   no
If No, what is the burial depth?  feet


7. Tank operating with pressure or vacuum (or neither)?
pressure  (psi, N/cm2 , in. H2O, ft H2O, etc.) (ma 1 psi)
vacuum   (in. H2O, in. Hg, mm Hg, etc.)
 neither


8. If the chemicals to be stored in the tank were to leak to the environment would any of the following be required:
a) an environmental cleanup: yes   no   unknown
b) reporting to any government agency: yes   no   unknown
c) fines to any government agency: yes   no   unknown


9. How will the chemical(s) be stored in the tank?
continuously    in an emergency

(Note: When used as an emergency dump tank, the customer may be required to flush the tank of the chemicals after a dump depending on the resin selected for the manufacturer of the tank.)

10. Is the fluid/chemical soluble in water?  yes   no   unknown


11. If a mixture, will the mixture phase separate or stay in solution?
phase separate   stay in solution   unknown


12. Will the chemical(s) be under constant agitation? yes   no   unknown


13. Will a chemical process or the mixing of chemicals be done in the tank?
yes   no

If Yes, identify the reaction or mixing process, the chemicals used or created, presence of agitation (continuous or intermittent), quantify the heat generation, how chemicals are introduced into the tank (i.e., drop tube, side wall port, etc.):



14. What are the normal operating temperatures?
Minimum (°F)       Maximum (°F) 


15. List temperature deviations from normal operating conditions, the time interval of the temperature deviation, and the expected frequency of the temperature deviations.
Minimum (°F)   How long hrs   days     Frequency
Maximum (°F)   How long hrs    days     Frequency

Use this space for additional comments or questions:
 
 

Note: Failure to answer questions or supply complete information about the chemical(s) or mixture to be stored in the tank may cause delays in the approval process.