DERR-2024-005831

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Show locations of all buildings, streets, tanks, piping and dispenser islands. lndicate location and depth ol all samples collected by the sampler and the inspector
Also indicate the location ol any reported PID or FID readinos.
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Surface Water Sewer Line Water Line Natural Gas Line
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TANK REMOVER Name 6m--, luswatt cert. # TR D)trfl Exp. dare-4LZL
Company Lr&rtlerFe epurrrca,pg'rFrrL -Er->L phone#( )
Address Z{6a 7cz.:> SC:, l* >{Z City SLa Srate..!2T- Zip_HJ_L l_
SOIUGRoUNDWATER SAMPLER tlame .G:.hrl+l 6+:a,r Cert. # GS lb6 Exp. date-ff/a.!,
Company Af&rtr;rlna &.ru(ErF{a\r>,+L -q=L- phone # ( )
Address 4g 6A C )@o , r+ z-l1-ciry 3L(- Stateul- ziffi_ll-l_
Before the closure plan is submitted for approval, the local health and fire departments where the facility is locatedmust be contacted- ff the facitity is in Beaver, Carbon, Emery, Garfcld, Grand, lron, Kane, Satt Lake, San Juan, wasatch, or washington county
6ntad DERR (UST) et (801)5364100 instead of the loca! health district. You slill must contad the tocal fire dewftment in these counties.
1
CONTACT LOCAL HEALTH DISTR|CT Name of Dist.
Contact
CONTACT LOCAL FIRE DEPT. Name of Dept.
Contact
Phone #
Date
Title Phone #
DISPOSAL INFORMATION
Tank(s) will be disposed at: Facility
Address City
Contact person
Product lines will either be:>removed or
vent lines will either oe: (. removed or
-
creaned and secured open.
Piping will be disposed at: Facitity
Address q72-l w 1q19o City 5t-<- Statebt- Zip_aslle:I_
Contactperson hr-r*ntZ. Pe,r=rr*-r-: phone#( )a?S--3(6S
Tank(s) will be emptied by: company UrS. Et^r,rr-^rt-r,*rrrr,- phone # ( ) S-1ti - Bt rl
Tank(s) will be cleaned by: company U.C Er.-rurfro,^rpr*.ro*-Phone#( ) S>S--EIS-l
Contaminated water in the tanUrinsate will be disposed at Facility
Contactperson tlzr.lrJ phone#(
Tank(s) will be: purged or K rendered inert by thefoflowing method: DDJ) EzE
Residual sludges will be disposed at the following facitity: t/.r5. EtfUrpor-+rr=prztu
Address /SS tJ SZ2OIL)city__t_(-_(-_ State !rf- zi p__31!_!_le_
Contact person .\ort*,Phone#( ) flf- B,t,
State_ Zip
Phone#( )
cleaned, secured in place, and capped.
FOR CLOSURE IN.PLACE ONLY
[ ] Approval for in-place closure has been granted by the Local Fire Department.
Fire Dept.Phone#_ Contact Date
[ ] Approval for in-place closure has been granted by the Local Health Department.
Health District_phone#_ Contact_ Date
CONTAMINATED MATERIALS JT BE DISPOSED AT AN ACCEPTABLE I .LITY:
All materials generated from UST closures must be managed and disposed in a manner that does not place those materialsin direct contact with the environment. On-site stockpiling of contaminated soils may be required prior to any soil
management activities. A ny person providing remedial assistane for a fee, including aeration and over-excavation (of more
than 50 yd), must be a Certifled uST Consuttant.
Contaminated soils generated as part of tank removal are to be disposed at the following facility:
E. l'. [-a.*r-pr.q^rgs nooress 61?6 tl t3<r- S. city 5ec
I The following modifications to th
A. Dual column confirmation may not be required for TPH & BTEXI.iA4TBE analysis.B. A micro-extraction or scale{own technique may be used for aqueous samples.C. Hexane may be used as an extraction solvent.NOI'E: 'lhe sample preparation method and any modification(s) to a certified method must be reportcd by the laboratory on thefinal analytical report.
2 Methods or test procedures allowed for Oil and Grease (O&G) or Total Recoverable Petroleum Hydrocarbons (TRPH) are 5520(b) or 5520(f1respectively.
Complete the Facility Site Plat and Sample tnformation Table on pages 4 and S to provide site assessmentinformation.
CONTAMINATION INFORMATION
lf contamination at the facility is susoected or confirmed, the information must be reported to the Executive Secretary (UST)at [phone] within 24 hours. The Division of Water Quality must be notified at [phone] if Free product isencountered or if surface water has been impacted. lf contamination is confirmed, any person assisting in the remediationprocess for a fee must be a Certified UST Consultant.
a
State_ L2I Zlp_S-t *L Conracr person l}-*l) phone # L I Lf L -1t; I
SITE ASSESSIT'ENT
Soil
in the following table, using appropriate
Substance or
Product Type
Contaminant Compounds to be Analyzed ANALYTICAL
METHODS
Soif Groundwater
or Surface Water
Gasoline Total Petroleum Hydrocarbons (TPH); and Benzene, 'loluene,
Ethyl benzene, Xylenes, Naphthalene, (BTEXN) and MTBE
EPA 801 58 I and EPA
80218 | or 82608
Diesel Total Petroleum Hydrocarbons (TPH); and Benzene, Toluene,
Ethyl benzene, Xylenes, and Naphthalene (BTEXN)
EPA 80158 and EPA
8021 B or 82608
Used Oil Oil and Grease (O&G) or Total Recoverable petroleum
Hydrocarbons (TRPH); and for Benzene, Toluene, Ethyl-
benzene, Xylenes, Naphthalene (BTEXN) & MTBE; and
I{alogenated Volatile Organic Compounds (VOC's )
EPA 1664or55202
and EPA 80218 or
82608
New Oil Oil and Grease (O&G) or Total Recoverable Petroleum
Hydrocarbons (TRPH)
EPA 1664 or 5520
Other or
Unknown
Total Petroleum Hydrocarbons (TPH); and Benzene, Toluene,
Ethyl benzene, Xylenes, and Naphthalene (BTEXN): and
Ilalogenated Volalile Organic Compounds (VOC's)
EPA 80158 and EPA
8021 B or 82608
and
lab
A site asseasment must be performed for all UST closures and change-in-service. Site assessments must beperformed as outlined in 40 CFR 280.72 and R311-205 (U.A.c.). lf contJmination is suspected. additionalsamples
be analyzed for the compounds shown
1 ' FACILITY SITE PLAT (CLOSURE PLAN i
The site plat must be drawn to an appropriate identified scale. lt must show planneo sampling locations, substiances stored
in tanks, and other relevant information. Tank and sample identification numbers must be consistent with the information
given on p. 1 and 5 of the Closure Plan.
Facitity tD #- Drawn * 4".-', , - e. L*--= - Dateq:#3Jd\-
1I
NORTH
Scale: 1"= rfr*t {TerzoX .
bbc> S.'. Sf.
2"A G. S;ac2so.
t'c2T^ o'-'Dv7L
G*-t
?qrr--,rr.- r@-rveG-
X - Sample locations (SS-#, WS-#, USC-#)
ao : Monitoring Wells (MW-#,)
O : Soil boring (SB-#), orGeoprobe Boring(Gp-#)O : Water Wells (domestic, livestock, etc.)
Slope of Surface Topography: (N,NW,W,SW,S,SE,E,NE)
Land l.ise At Site: _Residential _Commercial _tndustrial
Surrounding Land: _Residential _Commercial _lndustriai
Site Plat Must Indicate Approximate Lmations Of:y' Current & fonnertank, piping & dispensersy' Location of ail samples to be iaken/ Buildings, fences, & property boundariesy' Utility conduits (s€wers, gas, water, storm drains,
electrical, etc.)
SAMPLE INFORMATION TABLE
Complete table for all samples to be taken for closure.
Sample #Substance
stored in
tank
Sample
typet
Depth2 Compounds3 Analysis method(s)a
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53 -Ll ,l tl tl 1l tl ,l
Soil (SS), Groundrvater (GW), or Unified Soil Classification (USC)
Approx. depth in feet belol , grade. The required minimum site assessrnent samplB must be teken at G2 feet below the backfill/native soil interface.Contaminant compoinds to be anallzed for each sample (trorn table on p. 3).
Appropriate analysis methods for contaminant compound(s) in each sample ifrom table on p. 3).
Approximate depth to groundwater in the vicinity of the tanks: t L ' feet.
Regional groundwater flow direction: L<>Ea l-
1
1
2
3
4
State Certified Laboratory to be usd: l^{q|Er>ttnJ c.t-z tzs,f t#vt+ rr t-,fz
Address ar63 t). 36ac2 5 . city 5r_L state rJ I- zip_*1_llF
Contact person G?-OL3A.Phone # (*ztl 2J-g -asz:- Ab
lcertify under penalty of law that I am the owner/operator of the tank(s) referenced above and that I am fumiliar withthe information on this form and that it is true, accurate and complete, and further, that the procedures describedherein will be followed during tank closure.
Signature of tank owner
Full Name of tank owner
Please explain any unusual or extenuating circumstances expected regarding the site assessment or closure:
Date