DERR-2024-008846

1
PETROLEUM STORAGE TANK CLOSURE PLAN (rev. 10/21) FACILITY ID# …
LHD USE ONLY
Date Received
Reviewer
Date LHD Approved
Date mailed to State
Closure Plan prepared at the request of the owner/operator (identified below) by
of (company name) Phone #
Address City State Zip
A Contractor may prepare this Closure Plan as the owner/operator's agent. In preparing the Closure Plan, the Contractor must act with
the owner/operator's knowledge and approval. The owner/operator must sign the Closure Plan. Submit Closure Plan to: DERR/PST,
P.O. Box 144840, Salt Lake City, Utah, 84114-4840
This Closure Plan is submitted in compliance with the requirements contained in 40 CFR 280 Subpart G and U.A.C. R311-204.
Piping closure only Tank #
Tank Type (Steel,FRP,etc.)
Piping Type (Steel,FRP,etc.)
Date Installed
Capacity
Substance stored*
Date last operated
Removal/In Place/Change in
Service (CIS)?
*Indicate the specific substance stored in each tank to be closed (gasoline, diesel, new oil, waste oil, etc.)
For waste oil tanks: Have degreasing or other types of solvents been stored or mixed with the waste oil?
Yes (identify if known) . No Not Known
Analysis for lead or other contaminants may be required prior to disposal of contaminated soil or other material. (Check with your
disposal facility.)
STATE USE ONLY
Date Received
Date Mailed to LHD
Date Received From LHD
Reviewer/Date Approved
Mgr. Review/Date
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
Total number of regulated petroleum storage tanks at this site to be closed
2
Before the closure plan is submitted for approval, the local health and fire departments where the facility is located
must be contacted.
CONTACT LOCAL HEALTH DISTRICT: Name of Dist. Date
Contact Title Phone#
CONTACT LOCAL FIRE DEPT. Name of Dept. Date
Contact Title Phone#
DISPOSAL INFORMATION
Tank(s) will be disposed at: Facility
Address City State Zip
Contact person Phone#
Product lines will either be: removed or cleaned, secured in place, and capped.
Vent lines will either be: removed or cleaned and secured open.
Piping will be disposed at: Facility
Address City State Zip
Contact person Phone#
Tank(s) will be emptied by: company Phone#
Tank(s) will be cleaned by: company Phone#
Contaminated water in the tank/rinsate will be disposed at: Facility
Contact person Phone#
Tank(s) will be: purged or rendered inert by the following method:
Residual sludges will be disposed at the following facility:
Address City State Zip
Contact person Phone#
FOR CLOSURE IN PLACE ONLY
For this closure method, you are subject to the requirements of UAC R315-302-2(6), which requires annotating the property title and
submitting documentation to the Division of Waste Management and Radiation Control (DWMRC). For information on how to
comply with these requirements, contact the DWMRC Solid Waste Landfill Section Manager at [phone].
Approval for in-place closure has been granted by the Local Fire Department. (Must submit approval in writing with Closure Plan)
Fire Dept. Phone#Contact person Date
Approval for in-place closure has been granted by the Local Health Department.
Health Dept. Phone#Contact person Date
Substance to be used to fill tanks:
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
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SITE ASSESSMENT
A site assessment must be performed for all PST closures and change-in-service. Site assessments must be performed as outlined in 40 CFR
280.72 and U.A.C. R311-205. If contamination is suspected, additional samples must be collected at the location where contamination is
most likely to be present. If groundwater is encountered, a soil sample must be collected, in the unsaturated zone, in addition to each
groundwater sample. Soil and groundwater samples must be analyzed for the compounds shown in the following table, using appropriate lab
methods.
Substance or
Product Type
Contaminant Compounds to be Analyzed for Each
Substance or Product Type
ANALYTICAL METHODS1
Soil, Groundwater
or Surface Water
Gasoline
Total Petroleum Hydrocarbons (purgeable TPH as gasoline
range organics C6 - C10)
EPA 8015 or EPA 8260
Benzene, Toluene, Ethyl benzene, Xylenes, Naphthalene,
(BTEXN) and MTBE
EPA 8021 or EPA 8260
Diesel
Total Petroleum Hydrocarbons (extractable TPH as diesel
range organics C10 – C28)
EPA 8015
Benzene, Toluene, Ethyl benzene, Xylenes, and Naphthalene
(BTEXN)
EPA 8021 or EPA 8260
Used Oil
Oil and Grease (O&G) or
Total Recoverable Petroleum Hydrocarbons (TRPH)
EPA 1664 or
EPA 1664 (SGT*)
Benzene, Toluene, Ethyl benzene, Xylenes, Naphthalene
(BTEXN) & MTBE; and Halogenated Volatile Organic
Compounds (VOX)
EPA 8021 or EPA 8260
New Oil Oil and Grease (O&G) or
Total Recoverable Petroleum Hydrocarbons (TRPH)
EPA 1664 or
EPA 1664 (SGT*)
Other Type of analyses will be based upon the substance or product
stored, and as approved by the DERR Division Director
Method will be based upon the
substance or product type
Unknown
Total Petroleum Hydrocarbons (purgeable TPH as gasoline
range organics C6 - C10)
EPA 8015 or EPA 8260
Total Petroleum Hydrocarbons (extractable TPH as diesel
range organics C10 – C28)
EPA 8015
Oil and Grease (O&G) or
Total Recoverable Petroleum Hydrocarbons (TRPH)
EPA 1664 or
EPA 1664 (SGT*)
Benzene, Toluene, Ethyl benzene, Xylenes, and Naphthalene
(BTEXN) and MTBE; and Halogenated Volatile Organic
Compounds (VOX)
EPA 8021 or EPA 8260
1 The following modifications to these certified methods are considered acceptable by the DERR Division Director:
Dual column confirmation may not be required for TPH and BTEXN/MTBE analysis.
A micro-extraction or scale-down technique may be used for aqueous samples, but only for the determination of extractable TPH as diesel range
organics (C10 – C28).
Hexane may be used as an extraction solvent.
*Silica Gel Treatment (SGT) may be used in the determination of Total Recoverable Petroleum Hydrocarbons.
NOTE: The sample preparation method and any modification(s) to a certified method must be reported by the laboratory.
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CONTAMINATED MATERIALS MUST BE DISPOSED AT AN ACCEPTABLE FACILITY:
All materials generated from PST closures must be managed and disposed in a manner that does not place those materials in direct contact
with the environment. On-site stockpiling of contaminated soils may be required prior to any soil management activities. Any person
providing remedial assistance for a fee, including aeration and over-excavation (of more than 50 yd3), must be a Certified UST Consultant.
Contaminated soils generated as part of tank removal are to be disposed at the following facility:
Address City State Zip
Contact person Phone
Complete the Facility Site Plat and Sample Information Table on pages 4 and 5 to provide site assessment information.
CONTAMINATION INFORMATION
If contamination at the facility is suspected or confirmed, the information must be reported to the DERR Division Director at (801) 536-
4100 within 24 hours. The Division of Water Quality must be notified at [phone] if Free Product is encountered or if surface water
has been impacted. If contamination is confirmed, any person assisting in the remediation process for a fee must be a Certified UST
Consultant.
SAMPLE INFORMATION TABLE
Complete table for all samples to be taken for closure.
1 Soil (SS), Groundwater (GW), or Unified Soil Classification (USC). 2 Approx. depth in feet below grade. The required minimum site assessment samples must be taken at 0-2 feet below the backfill/native soil interface. 3 Contaminant compounds to be analyzed for each sample (from table on p. 3). 4 Appropriate analysis methods for contaminant compound(s) in each sample (from table on p. 3).
Sample
#
Substance
stored in
tank
Sample
type1 Depth2 Compounds3 Analysis method(s)4
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Facility Site Plat (Closure Plan)
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 pages 1 and 4 of the
Closure Plan.
Facility ID: Drawn By:Date:
X = Sample locations (SS-#, WS-#, USC-#) Site Plat Must Indicate Approximate Locations of:
●= 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
Surrounding Land: _ Residential Commercial Industrial
North Scale: 1”= Feet
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Approximate depth to groundwater in the vicinity of the tanks: feet.
Regional groundwater flow direction:
State Certified Laboratory to be used:
Address City State Zip
Contact Person Phone
I certify under penalty of law that I am the owner/operator of the tank(s) referenced 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
will be followed during tank closure.
Signature of tank owner
Full Name of tank owner Date
Please explain any unusual or extenuating circumstances expected regarding the site assessment or closure: