MO-29928_0_CA_UST-3_20230523_Permanent Closure

UST-3 Notice of Intent: UST Permanent Closure or Change-in-Service
Return completed form to:
The DWM Regional Office located in the area where the facility is located. Also send a copy to the Central Office in Raleigh.
SEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES.
STATE USE ONLY
I.D. #_____________________
Date Received______________
INSTRUCTIONS (READ THIS FIRST)
Complete and return a UST-3 form at least thirty (30) days prior to closure or change-in-service activities. 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 then at least a five
(5)working days’ notice is acceptable.
Completed UST closure or change-in-service site assessment reports, along with a copy of the UST-2A and/or 2B forms, should be submitted to the
appropriate Division of Waste Management (DWM) Regional Office within thirty (30) days following closure activities. The UST-2 form should also be
submitted to the Central Office in Raleigh so that the status of the tanks may be changed to permanently closed and your tank fee account can be closed out.
Note: Tank fees may be due for unregistered tanks.
UST closure and change-in-service site assessments must be completed in accordance with the latest version of the Guidelines for Site Checks, Tank Closure
and Initial Response. The guidelines can be obtained at https://deq.nc.gov/about/divisions/waste-management/ust. Note: To close tanks in place you must
obtain prior approval from the DWM Regional office located in the region where the facility is located.
You must make sure that USTs removed from your property are disposed of properly. When choosing a closure contractor, ask where the tank(s) will be
taken for disposal. Usually, USTs are cleaned and cut up for scrap metal. This is dangerous work and must be performed by a qualified company. Tanks
disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment. If your tanks are disposed of improperly, you
could be held responsible for the cleanup of any environmental damage that occurs.
I. OWNERSHIP OF TANKS II. LOCATION
Owner Name (Corporation, Individual, Public Agency, or Other Entity)

Facility Name or Company

Street Address
Facility ID # (If known)

City

County
Street Address

State
Zip Code
City
County
Zip Code

Phone Number Email Phone Number

III. CONTACT PERSONNEL
Name:

Company Name:

Job Title:

Phone Number:

IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE-IN SERVICE
1.Contact local fire marshal.
2.Plan entire closure event.
3.Conduct Site Soil Assessment.
4.If removing tanks or closing in place, refer toAPI Publication 2015 Cleaning Petroleum
Storage Tanks and 1604 Removal and
Disposal of Used Underground Petroleum
Storage Tanks.
5.Provide a sketch locating piping, tanks and
soil sampling locations.
6.Submit a closure report in the format of UST-
12 (including the form UST-2) within thirty(30) days following the site investigation.
7.If a release from the tanks 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 the 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 L.G. is not required.
8.Keep closure records for three (3) years.
V. WORK TO BE PERFORMED BY
Contractor Name:

Contractor Company Name:

Address:

State:

Zip Code:

Phone No:

Primary Consultant Name:

Primary Consultant Company Name:

Consultant Phone No:

VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE-IN-SERVICE
Tank ID No. Size in Gallons Last Contents
Proposed Activity
Closure Change-In-Service
Removal Abandonment in Place * New Contents Stored

*Prior written approval to abandon a tank in place must be received from a DWM Regional Office.
VII. OWNER OR OWNER’S AUTHORIZED REPRESENTATIVE
Has a release from a UST system occurred at this location? Yes No Unknown
I understand that I can be held responsible for environmental damage resulting from the improper disposal of my USTs.
Print name and official title:
Signature Date Signed SCHEDULED REMOVAL DATE Notify your DWM Regional Office
48 hours before this date if
scheduled removal date changes
UST-3 Rev 3/2020
SAMS INVESTMENTS II, LLC
7935 COUNCIL PLACE STE 200
MATTHEWS MECKLENBURG
NC 28105-5000
704-209-4509 [e-mail]
SAM'S MART 109
00-0-0000010641
391 WEST PLAZA DRIVE
MOORESVILLE Iredell 28115
[phone]
Aaron Long Principal EngineerECEA 704-853-0800
Mike Holcomb Diversified Demolition
1431 Springwood Ln, Charlotte 28210 [phone]
Aaron Long ECEA
NC
704-853-0800
1 10,000 Gasoline ■
2 10,000 Gasoline ■
3 10,000 Gasoline ■
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Aaron Long, agent for SAMS INVESTMENTS II, LLC
1/4/2023 1/31/2023
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