MO-9180_40691_CA_UST-3_19980919

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GW/UST-3 Notice of Intent: UST Permanent Closure or Change -In -Service
j FOR Retum Completed Form To: State Use Only
TANKS The appropriate DWO Regional Office according to the county of the facility's 1. D. Number
IN location. (SEE REVERSE SIDE OF OWNER'S COPY (PINKS FOR REGIONAL Date Received
�] (� OFFICE ADDRESS].
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 and signs and
seals all closure reports. Otherwise, thirty (30) days notice is required.
L :aWNERSHIP OF TANK(S)
II. LOCATION OFTANK(S}
11
Tank Owner Name: O e �^� �� Facility Name or Company:��ovaiSh /� �.✓ C
tcwPx8b0 1M*VbL LPw*: Aq
Street Address:_7i '� '!7O / ,�iJ�, a 9 S Facility ID # (if available): O �OD BLOC
County: � r�—S Street Address or State Road: 770 �� `i Soo
City: Stater ;TB� Zip Code2S— County: City Zip Code �7s
- ��= � -- Tele. No. (Area Code): �f
Tele. No. (Area Code): 22K
' Ill. CONTACT PERSON
Name: iJob Title: a Telephone Number.O 2
IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE -IN-SERVICE
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".
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
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 LG. is not required.
8. Keep closure records for 3 years.
V. WORK TO BE PERFORMED BY:
(Contractor) Name: C L di•ct
Address: �_ GY/� Y� ' �G,1"10 State: 04/ • G • Zip Code: .�
Contact: A1�-e—.c� S 1�--°7 Phone: 8 " .✓�� Cif lna�
Primary Consultant: Phone:
VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE -IN-SERVICE
TANK ID# TANK CAPACITY LAST CONTENTS
PROPOSED ACTIVITY
CLOSURE
CHANGE-1N-SERVICE
3r DOD e— et
L 45SAO A4110-
Removal
Abandonment
In Place
New Contents Stored
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VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
Print name and official title
QJVe'!!; N , 4-4 ' 'Scheduled Removal Date:��
Cinnn?rn-l-%1 l 1'.O 1/11 r Slam_ Date Submitted:
n
If scheduled work date changes, notify your appropriate DWO Regional bffice 48 hours prior to originally scheduled date.
GWIUST-3 (Rev. 10/96) White Copy - Regional Office Yellow Copy - Central Office Pink Copy - Owner