MO-5532_19387_CA_UST-3_19980610

I
GMUST 3 Notice of'Intent: UST Permanent Closure or Change -In -Service
FOR Return Completed Form To: State USQ. 'nly
TANKS The appropriate DWQ Regional Office according to the county of the facility's
IN location. [SEE REVERSE SIDE OF OWNER'S COPY (PINK) FOR REGIONAL I. D. Number
NC OFFICE ADDRESS]. Date ReceivedU' I y i,
INSTRUCTIONS
Complete and return at least five (5) working days prior to closure or change -in-service if a Professiona ,.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. Otherwise, thirty (30) days notice is required.
t. OWNERSHIP OF TANK(S) 11. LOCATION OF TANKS}
Tank Owner Name: M P6 Ra4v --Facility Name or Company: -
(Corporation, Individual, Publi gency or Other jEnt -T
Street Address:cA mV a ofiarSoor/3 , 600� i�l� ,Facility ID # (if available):
a. r
County: cob f US ,' Street Address or State Road: 6 007 iiaor v Le).
City: I �0C State: NC Zip Code: 29075 County: rU3 City: r Jr Zip Code: 28079
Tele. No. (Area Code): Tele. No. (Area Code): 04 q55
III. CONTACT PERSON
Name: o orUSSo Job Title: MdoqAer Telephone Number: (M)y55- IZZ7
1V. TANK REMOVAL, CLOSURE 1N, LACE, CHANGE -IN-SERVICE
1. Contact Local Fire Marshall. 5. Provide a sketch locating piping, closure must be conducted under the
2. Plan the entire closure event. tanks and soil sampling locations. supervision of a P.E. or L.G., with all
13. Conduct Site Soil Assessments. 6. Submit a closure report in the format of closure site assessment reports bearing
4. If Removing Tanks or Closing in Place GW/UST-12 and include the form signature and seal of the P.E. or L.G.
refer to API Publications 2015 "Cleaning GW/UST-2 within 30 days following the If a release has not occurred, the
Petroleum Storage Tanks" & 1604 site investigation. supervision, signature, or seal of a P.E.
"Removal & Disposal of Used Under- 7. If a release from the tank(s) has occurred, or L.G. is not required.
ground Petroleum Storage Tanks". the site assessment portion of the tank 8. Keep closure records for 3 years.
V. WORK TO BE PERFORMED BY:
u
(Con ractor) Name: S De ,+ r U WI
Address: 0 , o X 735 1, 6 k a r iD HE, State:_ Zip Code:
Contact: V Phone: — 2-1
G SClrV'lc(S Phone: , `/ 525—SIS tv� Primary Consultant: to H tVly 6�ts
VI TA K S SCHE LED FOR CLOSURE OR CHANGE=1N-SERVICE
TANK ID# TANK CAPACITY LAST CONTENTS PROPOSED ACTIVITY
CLOSURE CHANGE -IN-SERVICE
ftn�A�C J / y� , Removal Aban P onaccent New Contents Stored
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VII OWNER OR OWNER'SAUTHORIZED REPRESENTATIVE
Print name and official title jj�� p
✓t k » - f 'Scheduled Removal Date:
Signature: Date Submitted:0 g
f scheeuled work date changes, notify your approp to DWQ Regional Office 48 hours prior to originally scheduled date.
:+'4/UST -; (R,-_,v. 10/96) `Nh;te �;cpy - Regional Office Yellow Copy - Centrai Office