MO-1370_0_CA_UST-3_19940106

FOR North Carolina - Department of Erwironmert, HeaM),cW�,M,`�ybrJrq'Aw es State i �iMENT, HEALTH ,
,YANKS Division of Emirorxnental Management - Gr tf�" a��a �i r WX UAL RESOURCES
IN P.O. Box 27687 .N01%.,nt� � � �pn� � I. D. Number
N Raleigh, NC 27611 (919)73�r=8303 O 1`39� �k Date Recei WN _
INSTRUCTIONS r t, E4i+FR�
Please complete and return thirty (30)., $"Pri*3 211 anently dosing tank(sp)NON OF ENVII?ONMENTAL Wlii10EME
1. OWNERSHIP OF TANK(S) U., IL LOCATION OF TANK(S)
Tank Owner Name: (! ayo 't-�rz., 4�0 . _Facility Name or Company: K -Tv fie=
(Cf!e*n, IrxfML4 Pubic Agency, or Other. Fntry
Street Address: `75� I i C-) C, a9 1 Street Addre --r State Toad: ry fie- nd d-
County: C4_16Ao�' rL t-5 CountyCIA
City: COO t) TzJ State:_ J�Zip Code: 02 602s City: V<aj i S State: QC— Zip Code: 02 808 I
Telephone Number (Area Code): r 6_� - `­1 g9,- 3l q (- Telephone Number (Area Code):
r- Contact Person
Name: VorJe�r+ �a rbowti' Job Title:6D• Super✓r -5�y­ Telephone Number:( 7cq-) M2- 3(9(,
TANK REMOVAL OR CLOSURE IN PLACE
1. Contact Local Fire Marshall. 4. Remove Tanks or Close in Place in a Safe 5. Provide a sketch Locating
2. Plan the Closure Event. and Secure Manner Per API Pubs. "2015 Tanks and Soil Tests.
3. Make Site Soil Assessments. Cleaning" and "1604 Removal & Disposal". 6. Keep Records for 3 Years.
TANK(S) CLOSURE OPERATIONS TO BE PERFORMED BY:
(Contractor) Name: et�y,' ro - T(Lf1 `K___
Address, � � Bc) (__ a as State e,,-) 5 � C-- Zip Code 916(0 &
Contact: I�r ( (�S Phone: qCD q-- eA(- Co 00c,
1 TANK(S) SCHEDULED FOR CLOSURE OR TO BE CLOSED
TANK NUMBER TANK ID # TANK CAPACfrY LAST CONTENTS CLOSURE METHOD_
Remove Close in Ground
Tank 1
Tank 2 l�
Tank 3 l�
Tank 4 0
Tank 5 0
Tank 6 O O
Tank 7 O
Tank 8 O O
Tank 9 O O
Name and Official title of Owners AL&ffaed Representative c r
0t)e t'a�ClofJ5 4 cA L V&5or'Scheduled Removal Date: gh
Signature: Date Submitted: �v
'N whedijied removal dale changes, Fo V egfit hays verbal notice of lark removal is wFired
GW/U ST-? copy - Lmner blue wEry - +,1-_t11uc' vrircz

K-TOWN STORE
CENTERGROVE RD (DALE EARNHARDT)& UTAH
0-019494
NOI SUBMITTED DATED 1/06/94 FOR ONE UST
REGISTRATION DBASE INDICATES THAT 1-550 KERO TANK WAS REMOVED
FROM SERVICE 6/30/94 NO TANK CLOSURE REPORT RECEIVED, ROBBY
BARBOUR SAID NO 550 TANK EVER PRESENT EGL 10/18/05

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