DERR-2024-008861

1
PETROLEUM STORAGE TANK PERMANENT CLOSURE NOTICE (rev. 10/21) FACILITY ID# .
…
State Use Only
Date Processed by
Date Mailed to LHD
LUST ID#
Date to LUST Review
Closure Notice prepared at the request of the owner/operator (identified below) by
of (company name) Phone #
Address City State Zip
TANKS CLOSED
Piping Only Tank #
Please complete for each tank
Type (Steel,FRP,etc.)
Date Installed
Capacity (Gallons)
Substance stored*
Date last operated
Date Closed
Removed/In Place/Change in
Service (CIS)?
*Indicate the specific substance stored in each tank to be closed (regular, unleaded, diesel, waste oil, etc.)
CLOSURE INFORMATION
Fuel was emptied Sludge was removed Tank was cleaned
Tank was: Purged Inerted Method Used:
Location of Closure Records:
For In-Place Closure: tanks filled with:
For Change-In-Service: Substance to be stored:
FACILITY INFORMATION
Tank Owner Phone #
Address City State Zip
Facility Name
Address City State Zip
Contact person Phone #
Total number of regulated petroleum storage tanks at this site before closure
Total number of regulated petroleum storage tanks at this site after closure
TANK REMOVER Name Cert. # TR Exp. Date
Company Phone #
Address City State Zip
SOIL/GROUNDWATER SAMPLER Name Cert. # GS Exp. Date
Company Phone #
Address City State Zip
2
DISPOSAL SITES USED
Location Name Contact Name Phone # Date Amount
Tank(s) Tank #
Product From Tank(s)
Contaminated Water
From Tank Cleaning
Sludge
Contaminated Water
From Excavation
Contaminated Soil
SITE ASSESSMENT
Complete the Facility Site Plat (Closure Notice) and Sample Information Table (Closure Notice) on pages 3 and 4 to show the locations,
depths, and other information on all soil/groundwater samples taken for closure. The samples must be consistently identified by sample ID #
on the site plat, table, and lab analysis report.
Completed Facility Site Plat (Closure Notice) is attached.
The following must be included (enter the distance, and direction (N,S,E,W) from the area of contamination or, where applicable,
use OH for overhead, NP for not present):
Water Line Sewer Line Natural Gas Storm Drain Telephone Electrical Property Line Buildings
Completed Sample Information Table (Closure Notice) is attached.
Certified lab analytical environmental sample results are attached.
Unified Soil Classification (USC) sample results are attached.
Chain of Custody form is attached.
Samples were properly: Collected Labeled Packaged Transported
Samples were in sight of the person in custody at all times or in a secured locked place.
I certify under penalty of law that the closure site assessment at this facility was conducted in accordance with 40 CFR
280.52, 40 CFR 280.72, and U.A.C. R311-205, and that any additional samples required by 40 CFR 280.52, 40 CFR 280.72 and
U.A.C. R311-205-2(1)(a) were properly collected.
Signature of Certified Groundwater/Soil Sampler
Full name of Certified Sampler Date
If contamination at the facility is confirmed, any person providing remedial assistance for a fee must be a Certified UST Consultant. The
Certified UST Consultant providing assistance is:
CERTIFIED UST CONSULTANT
Name Cert. #CC Exp. Date
Company Address
City State Zip Phone #
Please explain any unusual circumstances that occurred during the site assessment or closure:
3
Facility Site Plat (Closure Notice)
The site plat must be drawn to an appropriate identified scale. It must show planned sampling locations, substances stored in tanks, and
other relevant information. Tank and sample identification numbers must be consistent with the information given on p. 1 and 4 of the
Closure Notice.
Facility ID: Drawn By: Date:
X = Sample locations (SS-#, WS-#, USC-#) Site Plat Must Indicate Actual Locations Of:
0 = Monitoring Wells (MW-#) √Current & former tanks, piping & dispensers
= Soil boring (SB-#), or Geoprobe Boring (GP-#) √ Location of all samples to be taken
●= Water Wells (domestic, livestock, etc.)√ Buildings, fences, & property boundaries
Slope of Surface Topography: (N,NW,W,SW,S,SE,E,NE)√ Utility conduits (sewers, gas, water, storm drains, electrical, etc.)
Land Use At Site: Residential Commercial Industrial √ Depth to groundwater (if encountered)
Surrounding Land: Residential Commercial Industrial √Excavations, GW monitoring wells & soil stockpiles
North Scale: 1”= Feet
4
SAMPLE INFORMATION TABLE (Closure Notice)
Complete table for all samples that were taken for closure. Sample ID numbers on the table must be consistent with the sample ID
numbers given on the site plat and in the lab analysis report.
1 Soil (SS), Groundwater (GW), or Unified Soil Classification (USC).2 Final depth (in feet) below grade at which samples were taken.3 Contaminant compound(s) analyzed for each sample (TPH, BTEXN, O&G, etc).
4 Appropriate analysis methods for contaminant compound(s) in each sample
State Certified Laboratory used
Address City State Zip
Contact Person Phone #
I certify under penalty of law that I am the Owner of the tank(s) described above and that I am familiar with the information on this form
and that it is true, accurate and complete and further, that the procedures described herein were followed during tank closure.
Signature of PST owner
Full Name of owner Date
Return completed Closure Notice form, Facility Site Plat and Sample Information Table, Soil/Groundwater sample lab analysis results,
USC sample results, and Chain of Custody form within 90 days of PST Closure to:
Mailing Address:
State of Utah Dept. of Environmental Quality DERR / PST Section P.O. Box 144840 Salt Lake City, Utah 84114-4840
Sample
#
Substance
stored in tank
Sample
type1 Depth2 Compounds3 Analysis method(s)4
Street Address:
Multi Agency State Office Building 195 North 1950 West (First Floor) Salt Lake City, Utah 84116