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Home My WebLink AboutDERR-2024-004465United States Environmental Protection Agency Washington, DC 20460 Approval expires 04/30/24 OMB No.2050-0068 Notification for Underground Storage Tanks Implementing Agency Name And Address:IMPLEMENTING AGENCY USE ONLY ID NUMBER: DATE RECEIVED: TYPE OF NOTIFICATION DATE ENTERED INTO COMPUTER: A. NEW FACILITY OR ONE-TIME NOTIFICATION (previously deferred system) B. AMENDED C. CLOSURE OR CHANGE-IN- SERVICE DATA ENTRY CLERK INITIALS: OWNER WAS CONTACTED TO CLARIFY RESPONSES, COMMENTS: _____ Number of tanks at facility _____ Number of continuation sheets attached What USTs Are Included?An UST system is defined as any one or combination of tanks that is used to contain an accumulation of regulated substances, and whose volume (including connected underground piping) is 10 percent or more beneath the ground. Regulated USTs store petroleum or hazardous substances (see What Substances Are Covered below). This includes UST systems with field-constructed tanks and airport hydrant fuel distribution systems. What Tanks Are Excluded From Notification (see § 280.10 and § 280.12)? x Tanks removed from the ground before May 8, 1986; x Farm or residential tanks of 1,100 gallons or less capacity storing motor fuel for noncommercial purposes; x Tanks storing heating oil for use on the premises where stored; x Septic tanks; x Certain pipeline facilities regulated under chapters 601 and 603 of Title 49; x Surface impoundments, pits, ponds, or lagoons; x Storm water or wastewater collection systems; x Flow-through process tanks; x Liquid traps or associated gathering lines directly related to oil or gas production and gathering operations; x Tanks on or above the floor of underground areas, such as basements or tunnels; x Tanks with a capacity of 110 gallons or less; x Wastewater treatment tank systems; x UST systems containing radioactive material that are regulated under the Atomic Energy Act of 1954; x UST systems that are part of an emergency generator system at nuclear power generation facilities regulated by the Nuclear Regulatory Commission under 10 CFR part 50. What Substances Are Covered?The notification requirements apply to USTs containing petroleum or certain hazardous substances. Petroleum includes gasoline, used oil, diesel fuel, crude oil or any fraction thereof which is liquid at standard conditions of temperature and pressure (60 degrees Fahrenheit and 14.7 pounds per square inch absolute). Hazardous substances are those found in Section 101 (14) of the Comprehensive Environmental Response, Compensation and Liability Act of 1980, with the exception of those substances regulated as hazardous waste under Subtitle C of the Resource Conservation and Recovery Act. When And Who To Notify?Owners who bring USTs into use after May 8, 1986 must submit this notification form to the implementing agency within 30 days of bringing the UST into use. If the implementing agency requires notification of any amendments to the facility, send information to the implementing agency immediately. Penalties:Any owner who knowingly fails to notify or submits false information shall be subject to a civil penalty not to exceed $16,000 for each tank for which notification is not given or for which false information is given. INSTRUCTIONS AND GENERAL INFORMATION Please type or print in ink. Also, be sure you have signatures in ink for sections VIII and XI. Complete a notification form for each location containing underground storage tanks. If more than 5 tanks are owned at this location, you may photocopy pages 3 through 6 and use them for additional tanks. The primary purpose of this notification form is to provide information about the installation, existence, changes to, and closure of underground storage tank systems (USTs) that store or have stored petroleum or hazardous substances. The information you provide will be based on reasonably available records, or in the absence of such records, your knowledge or recollection. Federal law requires UST owners to use this notification form for all USTs storing regulated substances that are brought into use after May 8, 1986, or USTs in the ground as of May 8, 1986 that have stored regulated substances at any time since January 1, 1974. The information requested is required by Section 9002 of the Solid Waste Disposal Act (SWDA), as amended. Who Must Notify?40 CFR part 280, as amended, requires owners of USTs that store regulated substances (unless exempted) to notify implementing agencies of the existence of their USTs. Owner is defined as: x In the case of an UST in use on November 8, 1984, or brought into use after that date, any person who owns an UST used for storage, use, or dispensing of regulated substances; or x In the case of an UST in use before November 8, 1984, but no longer in use on that date, any person who owned the UST immediately before its discontinuation. Also, owners of previously deferred UST systems with field- constructed tanks and airport hydrant fuel distribution systems in the ground as of October 13, 2015 must submit a one-time notification of existence by October 13, 2018. Owners of UST systems with field- constructed tanks and airport hydrant fuel distribution systems brought into use after October 13, 2015 are considered new facilities and must follow the same notification requirements as all other UST owners. I. OWNERSHIP OF USTs II. LOCATION OF USTs Owner Name (Corporation, Individual, Public Agency, Or Other Entity)If required by implementing agency, give the geographic location of USTs either in decimal degrees, or degrees, minutes, and seconds. Example: Latitude: 36.123480 (or 36q 7' 24.4"), Longitude: -106.549876 (or -106q 32' 59.6") Latitude ________________ Longitude ________________ Street Address County Facility Name Or Company Site Identifier, As Applicable If address is the same as in Section I, check the box and proceed to section III. If address is different, enter address below: Street Address County City State Zip Code Phone Number (Include Area Code) City State Zip Code Utah Department of Environmental Quality, Division of Environmental Response and Remediation 195 North 1950 West,Salt Lake City,Utah 84116 ✔ 4 Walmart Inc. 40.493737 -111.417519 Walmart Fueling Station #4696 2101 SE Simple Savings Drive Benton Bentonville 479.258.2364 Heber City AR UT 72716 84032 1274 South US 189, Building B Wasatch EPA Form 7530-1 (Rev. 6-2015)Electronic and paper versions acceptable. Page 2 of 6 Previous editions may be used while supplies last. United States Environmental Protection Agency Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050-0068 Notification For Underground Storage Tanks III. TYPE OF OWNER IV. INDIAN COUNTRY Federal Government State Government Commercial Tribal Government Local Government Private USTs are located on land within an Indian reservation or on trust lands outside reservation boundaries Federally recognized tribe where USTs are located: V. TYPE OF FACILITY Auto Dealership Federal – Military Residential Commercial Airport Or Airline Gas Station Trucking Or Transport Contractor Industrial Utilities Farm Petroleum Distributor Other (Explain) ____________________ Federal – Non-military Railroad VI. CONTACT PERSON IN CHARGE OF TANKS Name:Job Title:Address:Phone Number (Include Area Code): VII. FINANCIAL RESPONSIBILITY I have met the financial responsibility requirements (in accordance with 40 CFR part 280 Subpart H) by using the following mechanisms: (check all that apply) Bond Rating Test Local Government Financial Test Surety Bond Commercial Insurance Risk Retention Group Trust Fund Guarantee Self-insurance (Financial Test)Other Method (describe here) Letter Of Credit State Fund ___________________________ I do not have to meet financial responsibility requirements because 40 CFR part 280 Subpart H is not applicable to me (e.g., if you are a state or federal owner). VIII. CERTIFICATION (Read and sign after completing ALL SECTIONS of this notification form) I certify under penalty of law that I have personally examined and am familiar with the information submitted in Sections I through XI of this notification form and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. Name and official title of owner or owner’s authorized representative (Print) Signature Date Signed Paperwork Reduction Act Notice The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Responses to this collection of information are mandatory (40 CFR 280.22). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050- 0068). Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. ✔ ✔ Sara Gallien Fuel Compliance Manager 2101 SE Simple Savings Drive, Bentonville, Arkansas, 72716 479.258.2364 ✔ ✔ EPA Form 7530-1 (Rev. 6-2015) Electronic and paper versions acceptable. Page 3 of 6 Previous editions may be used while supplies last. United States Environmental Protection Agency Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050-0068 Notification For Underground Storage Tanks IX. DESCRIPTION OF UNDERGROUND STORAGE TANKS (Complete for all tanks and piping at this location) Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 1. Status Of Tank (check only one) Currently In Use Temporarily Closed Permanently Closed 2. Date Of Installation (month/year) 3. Estimated Total Capacity (gallons) 4. Tank Attributes (check all that apply) Asphalt Coated Or Bare Steel Cathodically Protected Steel (impressed current) Cathodically Protected Steel (sacrificial anodes) Coated and Cathodically Protected Steel (impressed current) Coated and Cathodically Protected Steel (sacrificial anodes) Composite (steel clad with noncorrodible material) Concrete Fiberglass Reinforced Plastic Noncorrodible Tank Jacket Lined Interior Excavation Liner Double Walled Manifolded Compartmentalized Field-constructed Double Walled Unknown Other, Specify Here ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Check Box If Tank Has Ever Been Repaired 5. Overfill Protection Installed (check all that apply) Automatic Shutoff Flow Restrictor High-level Alarm Other, Specify Here ___________ ___________ ___________ ___________ ___________ 6. Spill Prevention Installed Double Walled 777T1 ✔✔✔✔ 09/19/2023 09/19/2023 09/19/2023 09/19/2023 20,000 12,000 8,000 20,000 ✔✔✔✔ ✔✔✔✔ ✔✔ ✔✔✔✔ ✔✔✔✔ Flapper Valve Flapper Valve Flapper Valve Flapper Valve ✔✔✔✔ ✔✔✔✔ EPA Form 7530-1 (Rev. 6-2015) Electronic and paper versions acceptable. Page 4 of 6 Previous editions may be used while supplies last. United States Environmental Protection Agency Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050-0068 Notification For Underground Storage Tanks Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 7. Piping Attributes (check all that apply) Bare Steel Galvanized Steel Fiberglass Reinforced Plastic Flexible Plastic Copper Cathodically Protected (impressed current) Cathodically Protected (sacrificial anodes) Double Walled Secondary Containment Airport Hydrant Piping Unknown Other, Specify Here ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 8. Piping Delivery Type (check all that apply) Safe Suction (no valve at tank) U.S. Suction (valve at tank) Pressure Gravity Feed 9. Substance Currently Stored (or last stored in the case of closed tanks) (check all that apply) *DVROLQHFRQWDLQLQJHWKDQRO Diesel Biodiesel Kerosene Heating Oil Used Oil *DVROLQH&RQWDLQLQJ!(thanol (specify amount of ethanol) ___________ ___________ ___________ ___________ ___________ 'LHVHO&RQWDLQLQJ!%iodiesel (specify amount of biodiesel) ___________ ___________ ___________ ___________ ___________ Other, specify here ___________ ___________ ___________ ___________ ___________ Hazardous Substance CERCLA Name Or CAS Number ___________ ___________ ___________ ___________ ___________ Mixture Of Substances Please Specify Substances Here ___________ ___________ ___________ ___________ ___________ ✔✔✔✔ ✔✔✔✔ ✔✔✔✔ ✔✔✔ ✔ EPA Form 7530-1 (Rev. 6-2015) Electronic and paper versions acceptable. Page 5 of 6 Previous editions may be used while supplies last. United States Environmental Protection Agency Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050-0068 Notification For Underground Storage Tanks Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 10. Release Detection (check all that apply) TANK PIPE TANK PIPE TANK PIPE TANK PIPE TANK PIPE Manual Tank Gauging Tank Tightness Testing Inventory Control Automatic Tank Gauging Vapor Monitoring Groundwater Monitoring Interstitial Monitoring (required for new or replaced tanks or piping) Statistical Inventory Reconciliation Automatic Line Leak Detectors Line Tightness Testing No Release Detection Required (such as some types of suction piping) Other Method Allowed By Implementing Agency Other, Specify Here ___________ ___________ ___________ ___________ ___________ X. CLOSURE OR CHANGE IN SERVICE 1. Closure Or Change In Service Estimated Date The UST Was Last Used For Storing Regulated Substances (month/day/year) ___________ ___________ ___________ ___________ ___________ Check Box If This Is A Change In Service (i.e., Change of storage to a non- regulated substance) 2. Tank Closure Estimated Date Tank Closed (month/day/year) ___________ ___________ ___________ ___________ ___________ (check all that apply below) Tank Removed From Ground Tank Closed In Ground Tank Filled With Inert Material Describe The Inert Fill Material Here ___________ ___________ ___________ ___________ ___________ 3. Site Assessment Check Box If The Site Assessment Was Completed Check Box If Evidence Of A Release Was Detected Other, Specify Here ___________ ___________ ___________ ___________ ___________ ✔✔✔✔ ✔✔✔✔ ✔✔✔✔ ✔✔✔✔ ✔✔✔✔ T1 T2 T3 T4