MO-0713_0_CA_UST-3_19960327

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Return Completed Form To: �da
ANKS
The appropriate DEM Regional Office according to the county of the facility's State Use Only
IN location. [SEE REVERSE SIDE OF OWNER'S COPY (PINK) FOR REGIONAL I. D. Number MAR A ILIS6—
NC OFFICE ADDRESS]. Date Received
INSTRUCTIONS Dwj5o% Cr
Complete and return five (5) working days prior to closure or change -in-service. IMOOKSVi LL � ,;"
Tank Owner Name:CT�A/ pnoP n�%�s Facility Name or Company: CaWJGs �ll S1D�✓�
(Corporation, Individual, Pubiip��y, pr Ot E,(ntit �)V / A N �v/
Street Address:_ /V f((� Facility ID # (if available):
County:/��.�% Street Address or State Road: 5�s /�� ewolial S
City: C%�� State: � Zip Code �� County: �jedn U� C/iitty: 4W69V Zip Code,fpc ',�
Tele. No. (Area Code): j Tele. No. (Area Code):
l Name: _'P11AAd J zr41— Job Title: �f SJrJ�iVT" Telephone Number:(��y) sy ? &T I
Contact Local Fire Marshall.
Plan the entire closure event.
Conduct Site Soil Assessments.
If Removing Tanks or Closing in
Place refer to API Publications
2015 "Cleaning Petroleum
Storage Tanks" & 1604 "Re-
moval & Disposal of Used
(Contractor) Name:
Underground Petroleum Storage Tanks"
Provide a sketch locating piping,
tanks and soil sampling locations.
Fill out form GW/UST-2 "Site
Investigation Report for
Permanent Closure" and return
within 30 days following the site
investigation.
7. The site assessment portion of the tank
closure must be conducted under the
supervision of a Professional Engineer
or Licensed Geologist. After January 1,
1994, all closure site assessment
reports must be signed and sealed
by a P.E. or L.G.
8. Keep closure records for 3 years.
Address: zep( ;? gd--S State: /U, (�• ,n, // Zip Code:
, KS
Contact: C ,V Phone: �a% '�~ �7 ,o U
Primary Consultant: Phone:
TANK ID# TANK CAPACITY LAST CONTENTS
Print name and official title
o�y
Signatu re:
Sl,
■:iallffl'd
CLOSURE CHANGE -IN-SERVICE
Removal Abandonment New Contents Stored
In Place
'Scheduled Removal Date: C/>—//- / 5
Date Subm itted: _�>_•
'If scheduled work date changes, notify ytW4ppropriate DEM Regional Office 48 hours prior to originally scheduled date.
GW/UST-3 (Rev. 05/94) White Copy - Regional Office Yellow Copy - Central Office Pink Copy - Owner

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MO-0713, Incident #
Cabarrus County
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