MO-9474_0_CA_UST-3_20190329

UST=3 Notice of Intent: UST Permanent Closure or Change -in -Service
Return completed form to:
STATE Use ONLY
The DWM Regional Office located in the area where the facility is located. Also send a copy to the Central Office in Raleigh.
I.D. #
SEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES,
Date Received
INSTRUCTIONS (READ THIS FIRST)
Complete and return at least thirty (30) days prior to closure or change -in-service activities. If a Professional Engineer (P.E.) or a Licensed Geologist (L.G.)
provides supervision for closure or change -in-service site assessment activities and signs and seals all closure reports then at least a five (5) working
days notice is acceptable.
Completed UST closure or change -in-service site assessment reports, along with a copy of the UST-2 form, should be submitted to the appropriate Division
of Waste Management (DWM) Regional Office within thirty (30) days following closure activities. The UST-2 form should also be submitted to the Central
Office in Raleigh so that the status of the tanks may be changed to permanently closed and your tank fee account can be closed out. Note: Tank fees may
be due on unregistered tanks.
UST closure and change -in-service site assessments must be completed in accordance with the latest version of the Guidelines for Site Checks, Tank
Closure and Initial Response. The guidelines can be obtained at http://www.wastenotnc.org/. Note: To close tanks in place you must obtain prior approval
from the DWM Regional office located in the region where the facility is located.
You must make sure that LISTS removed from your property are disposed of properly. When choosing a closure contractor, ask where the tank(s) will be
taken for disposal. Usually, LISTS are cleaned and cut up for scrap metal. This is dangerous work and must be performed by a qualified company. Tanks
disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment. If your tanks are disposed of improperly, you
could be held responsible for the cleanup of any environmental damage that occurs.
I. OWNERSHIP OF TANKS
11. LOCATION
Owner Name (Corporation, Individual, Public Agency, or Other Entity)
Facility Name or Companyy
Mr. Lonq Hu nh
Graham Construction Co
Street Address
Facility ID # (If known)
5868 Crimson Oak Court
00-0-0000025325
City County
Street Address
Harrisburg Cabarrus
830 Dolly Street NW
State Zip Code
City County Zi Code
NC 28075
Concord Cabarrus 28g27
Phone Number
Email
Phone Number
[phone]
lanile naliamc mail.com
III. CONTACT PERSONNEL
Name:
Company Name:
Job Title:
Phone Number:
Mr. Long Hu nh I
Owner
[phone]
IV, TANK REMOVAL, CLOSURE IN PLACE, CHANGE -IN SERVICE
1. Contact local fire marshal. 5. Provide a sketch locating piping, tanks and a P.E. or L.G., with all closure site
2. Plan entire closure event, soil sampling locations. assessment reports bearing the signature
3. Conduct Site Soil Assessment. 6. Submit a closure report in the format of and seal of the P.E. or L.G. If a release has
UST-12 (including the form UST-2) within not occurred, the supervision, signature or
4. If removing tanks or closing in place, refer to thirty (30) days following the site seal of a P.E. or L.G. is not required.
API Publication 2015 Cleaning Petroleum investigation. 8. Keep closure records for three (3) years.
Storage Tanks and 1604 Removal and
Disposal of Used Underground Petroleum 7.If a release from the tanks has occurred, the
Storage Tanks. site assessment portion of the tank closure
must be conducted under the supervision of
V. WORK TO BE PERFORMED BY
Contractor Name:
Contractor Company Name:
Steve Risch
Elite Environmental Services
Address:
State:
Zip Code:
Phone No:
322 Clarendon Estates Dr., Clover
SC
29710
[phone]
Primary Consultant Name:
Primary Consultant Company Name:
Consultant Phone No:
Maryse Speckner
PM Environmental, Inc.
[phone]
VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE -IN-SERVICE
Proposed Activit
Closure
Change -in -Service
Tank ID No.
Size in Gallons
Last Contents
Removal
Abandonment in Place
New Contents Stored
001
2000
gasoline
■❑
❑
❑
❑
Li
* Prior written approval to abandon a tank in place must be received from a DWM Regional Office.
VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
I understand that I can be held responsible for environmental damage resulting from the improper disposal of my USTs.
Print name and official title: Maryse Speckner / Sr. Project Consultant
Signature
D to Signed i
SCHEDULED REMOVAL DATE
Notify your DWM Regional Office
1 q
2/8/2019
48 hours before this date if
date
scheduled removal changes
UST-3 Rev 1/2019