MO-4467_14610_CA_UST-3_19980618_Notice of Intent UST Permanent Closure or Change in Service

FOR Return Completed Form To: State USe ,Y111 )NIv ENT, RHA.LT
TANKS The appropriate DWO Regional Office according to the county of the facility's ' : ""j L t<E`'�'t
IN location. [SEE REVERSE SIDE OF OWNER'S COPY (PINK) FOR REGIONAL I. D. Number
NC OFFICE ADDRESS]. Date Received p
INSTRUCTIONS
Complete and return at least five (5) working days prior to closure or change -in-service if a Professional Engineer (P.E.) or a
Licensed Geologist (L.G.) provides supervision for closure or change -in-service site assessment activities: andsigns and
seals all closure reports. Otherwise, thirty (30) days notice is required.
Tank Owner Name: (—,XrA SP✓lrfjA) hHYrKi /[{[r'1• A.1
(Corporation, Individual, Public —00M OP, ,/� e,
Street Address: 6 f/r
County: 1_�.ARRK1R U S
City: C-01V041L�J' State:. Zip Code
Tele. No. (Area Code): 70 Y- R6—L 7
Name
1. Contact Local Fire Marshall.
2. Plan the entire closure event.
3. Conduct Site Soil Assessments.
4. If Removing Tanks or Closing in Place
refer to API Publications 2015 "Cleaning
Petroleum Storage Tanks" & 1604
"Removal & Disposal of Used Under-
ground Petroleum Storage Tanks".
(Contractor) Name:
Address:S/00
Contact:
Primary Consultant:
TANK ID# TANK CAPACITY
Job Title:
Facility Name or Company:
Facility ID # (if available):_
Street Address or State Road: c4d-V r�117ZIZ43r`. ;V 4
County G rvA,.:&GU City: CO OE ip Code:12
Tele. No. (Area Code): -%� c /d� 1X57
5. Provide a sketch locating piping,
tanks and soil sampling locations.
6. Submit a closure report in the format of
GW/UST-12 and include the form
GW/UST-2 within 30 days following the
site investigation.
7. If a release from the tank(s) has occurred,
the site assessment portion of the tank
0 00 0 i aC ii� yz/Cy
elephone Number:
closure must be conducted under the
supervision of a P.E. or L.G., with all
closure site assessment reports bearing
signature and seal of the P.E. or L.G.
If a release has not occurred, the
supervision, signature, or seal of a P.E.
or L.G. is not required.
Keep closure records for 3 years.
Removal Abandonment New Contents Stored
In Place
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Nrint name and official title
*Scheduled Removal Date:
Signature: Date Submitted:
*If scheduled work date changes, notify your appropriate DWQ Regional Office 48 hours prior to originally scheduled date.
GW/UST-3 (Rev. 10/96) White Copy - Regional Office Yellow Copy - Central Office Pink Copy - Owner

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