MO-1409_0_CA_UST-3_19910506_UST Permanent Closure or Change in Service

FOR Retum Completed Form To: IJAND MAUT'r' S;' GTf ^ � -- State Use Only
TheRegional/ !o
TANKS Office accorci rd7fc-01
appropriate DEM � to the cou �'`_of �' -° ���� IN Number
location. [SEE REVERSE SIDE OF OWNER'S COPY (BLUE FOR R 1991 GIONAL I. D. Nmbe
Date Nu IV
NC OFFICE ADDRESS].
INSTRUC17
T�I „ TComplete and return thirty (30) days I gr�oe.n vI ULo
Tank Owner Name: b'grqh. 0)qne "TCQGuer
(o«a«aibv� I r r &"
Street Address: T1 Lq tie S � cee-�
County: _C Gb 4 CN'5
City: p1 rotes State:! C Zip Code: 2MS l
Tele. No. (Area Code): ' /Q 1- 11 Z) 6
Facility Name or Company �. R,
Teo,y ue Weri t r��
Facility ID # (if available)
Street Address or State Road: P,5) 9 k (i e R ree . f
County: , (°q S _City:4WftP6aJ Zip Code:a1
Tele. No. (Area Code): Wei: ) - 900 -
I Name: (fil(61 L t d 1oAn Job Title: sse1 ul-1561- Telephone Number:('709 )?M-1603 I
1. Contact Local Fire Marshall. 5. Provide a sketch locating piping, tanks and soil
2. Plan the entire Closure event sampling locations.
3. Conduct Site Soil Assessments. 6. Fill out form GW/UST-2 "Site Investigation Report for
4. ff Removing Tanks or Closing in Place refer to API Permanent Closure" and return within 30 days
Publications. 2015 "Cleaning Petroleum Storage following the site investigation.
Tanks" & 1604 "Removal & Disposal of Used 7. Keep records for 3 years.
Underground Petroleum Storage Tanks".
(Contractor) Name: U U?rCq ii'e d(YM(b 1) QLQ 4l)
Address: 11 IS-6 Ae-V6 Roaa; GMCA- State: aorC4� �i 0 0 Zip Code: 910
Contact:ml ek �-, ('h 0c Ctn f ens Phone: 9d'�``�g�-i�b3
.:
VI 'CAN SCHEDULED :::FOR C. 0SURE OR : i IANGE-tN-SERVICE
TANK ID# TANK CAPACITY LAST CONTENTS PROPOSED ACTIVITY
CLOSURE CHANGE -IN-SERVICE
Removal I Abandonment New Cantert Stored
006 0,010o
Print name and official
Signatu
'Scheduled Removal` ate:1
Date Submitted, 6 ) ]
If scfeduled work date changes, notify your appropriate DEM Regional Office 48 hours prior b originally scheduled date.
GW/UST-3 Rev.3/91 W im Copy - Regional Office Yellow Copy - Central Office Bkje Copy - Owner