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Underground Storage Tank Notification Form Glossary APPENDIX C APPENDIX D

APPENDIX C

UNDERGROUND STORAGE TANK

NOTIFICATION FORM

C-1
D-6

 APPENDIX D Glossary
United States

Environmental Protection Agency

Washington, DC 20460

Form Approved.

OMB No. 2050-0068

Approval expires 3/31/98

Notification for Underground Storage Tanks

State Agency Name and Address: STATE USE ONLY

ID NUMBER:

DATE RECEIVED:

TYPE OF NOTIFICATION A. Date Entered into Computer

B. Data Entry Clerk Initials * C. Owner Was Contacted to Clarify Responses, Comments: A. NEW FACILITY * B. AMENDED * C. CLOSURE

 No. of tanks

 _____ at facility _____ No. of continuation sheets attached

INSTRUCTIONS

Please type or print in ink all items except “signature” in section V. This form must be

completed for each location containing underground storage tanks. If more than five (5) tanks

are owned at this location, photocopy the following sheets, and staple continuation sheets to

the form.

GENERAL INFORMATION

Notification is required by Federal law for all underground tanks that have been 3. septic tanks;

used to store regulated substances since January 1, 1974, that are in the ground as

of May 8, 1986, or that are brought into use after May 8, 1986. The information

requested is required by Section 9002 of the Resource Conservation and Recovery

Act (RCRA), as amended.

The primary purpose of this notification program is to locate and evaluate underground

tanks that store or have stored petroleum or hazardous substances. It is expected that

the information you provide will be based on reasonably available records, or in the

absence of such records, you knowledge, belief, or recollection.

Who Must Notify? Section 9002 of RCRA, as amended, requires that, unless exempted,

owners of underground tanks that store regulated substances must notify designated

State or local agencies of the existence of their tanks. Owner means--

(a) in the case of an underground storage tank in use on November 8, 1984, or brought

into use after that date, any person who owns an underground storage tank used for

storage, use, or dispensing of regulated substances, and

(b) in the case of any underground storage tank in use before November 8, 1984, but

no longer in use on that date, any person who owned such tank immediately before

discontinuation of its use.

(c) if the State so requires, any facility that has underground any changes to facility

information or tank system status (only amended tank information needs to be

included).

What Tanks Are Included? Underground storage tank is defined as any one or

combination of tanks that (1) is used to contain an accumulation of “regulated

substances,” and (2) whose volume (including connected underground piping) is 10% or

more beneath the ground. Some examples are underground tanks storing: 1. gasoline,

used oil or diesel fuel, and 2. industrial solvents, pesticides, herbicides or fumigants.

What Tanks Are Excluded? Tanks removed from the ground are not subject to

notification. Other tanks excluded from notification are:

1. farm or residential tanks of 1,100 gallons or less capacity used for storing motor

fuel for noncommercial purposes;

2. tanks used for storing heating oil for consumptive use on the premises where

stored;

4. pipeline facilities (including gathering lines) regulated under the Natural Gas

Pipeline Safety Act of 1968, or the Hazardous Liquid Pipeline Safety Act of 1979, or

which is an intrastate pipeline facility regulated under State laws;

5. surface impoundments, pits, ponds, or lagoons;

6. storm water or waste water collection systems;

7. flow-through process tanks;

8. liquid traps or associated gathering lines directly related to oil or gas production

and gathering operations;

9. storage tanks situated in an underground area (such as a basement, cellar,

mineworking, drift, shaft, or tunnel) if the storage tank is situated upon or above the

surface floor.

What Substances Are Covered? The notification requirements apply to underground

storage tanks that contain regulated substances. This includes any substance defined as

hazardous in Section 101 (14) of the Comprehensive Environmental Response,

Compensation and Liability Act of 1980 (CERCLA), with the exception of those

substances regulated as hazardous waste under Subtitle C of RCRA. It also includes

petroleum, e.g., 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).

Where To Notify? Send completed forms to:

When To Notify? 1. Owners of underground storage tanks in use or that have been

taken out of operation after January 1, 1974, but still in the ground, must notify by May 8,

1986. 2. Owners who bring underground storage tanks into use after May 8, 1986, must

notify within 30 days of bringing the tanks into use. 3. If the State requires notification of

any amendments to facility, send information to State agency immediately.

Penalties: Any owner who knowingly fails to notify or submits false information shall be

subject to a civil penalty not to exceed $10,000 for each tank for which notification is not

given or for which false information is submitted.

I. OWNERSHIP OF TANK(S) II. LOCATION OF TANK(S)

Owner Name (Corporation, Individual, Public Agency, or Other Entity) If required by State, give the geographic location of tanks by degrees, minutes, and seconds.

Examples Lat. 42, 36, 12 N Long. 85, 24, 17 W

Latitude __________ Longitude __________

Street Address Facility Name of Company Site Identifier, as applicable (if same as Section I,

mark box here)

4

Street Address

City State Zip Code

County City State Zip Code

Phone Number (include Area Code) County Municipality

EPA Form 7530-1 (Rev. 8-94) Electronic and Paper versions acceptable. Page 1 of 5

Previous editions may be used while supplies last.
*

*

United States

Environmental Protection Agency

Washington, DC 20460

Form Approved.

OMB No. 2050-0068

Approval expires 3/31/98

Notification for Underground Storage Tanks

III. TYPE OF OWNER IV. INDIAN LANDS

* Federal Government * Commercial

* State Government * Private

* Local Government

Tanks are located on land within an Indian Tribe or Nation:

Reservation or on other trust lands.

Tanks are owned by native American 

nation, tribe, or individual

V. TYPE OF FACILITY

* Gas Station * Railroad * Trucking/Transport

* Petroleum Distributor * Federal - Non-Military * Utilities

* Air Taxi (Airline) * Federal - Military * Residential

* Aircraft Owner * Industrial * Farm

* Auto Dealership * Contractor * Other (Explain) 

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 Subpart H

Check All that Apply

* Self Insurance * Guarantee * State Funds

* Commercial Insurance * Surety Bond * Trust Fund

* Risk Retention Group * Letter of Credit * Other Method Allowed - Specify

VIII. CERTIFICATION (Read and sign after completing all section)

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this 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 Signature Date Signed

authorized representative (Print)

Paperwork Reduction Act Notice

EPA estimates public reporting burden for this form to average 30 minutes per response including time for reviewing instructions, gathering and maintaining the data needed

and completing and reviewing the form. Send comments regarding this burden estimate to Chief, Information Policy Branch (2136), U.S. Environmental Protection Agency,

401 M Street, Washington D.C. 20460, marked “Attention Desk Officer for EPA.” This form amends the previous notification form as printed in 40 CFR Part 280, Appendix

I. Previous editions of this notification form may be used while supplies last.

EPA Form 7530-1 (Rev. 8-94) Electronic and Paper versions acceptable. Page 2 of 5

Previous editions may be used while supplies last.
United States

Environmental Protection Agency

Washington, DC 20460

Form Approved.

OMB No. 2050-0068

Approval expires 3/31/98

Notification for Underground Storage Tanks

IX. DESCRIPTION OF UNDERGROUND STORAGE TANKS (Complete for each tank at this location.)

Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 

1. Status of Tank (mark only one)

Currently In Use

Temporarily Out of Use

Permanently Out of Use

Amendment of Information

*****

*****

*****

*****

2. Date of Installation (mo./year)

3. Estimated Total Capacity (gallons)

4. Material of Construction (mark all that apply)

Asphalt Coated or Bare Steel

Cathodically Protected Steel

Epoxy Coated Steel

Composite (Steel with Fiberglass)

Fiberglass Reinforced Plastic

Lined Interior

Double Walled

Polyethylene Tank Jacket

Concrete

Excavation Liner

Unknown

Other, Please specify

Has tank been repaired?

*****

*****

*****

*****

*****

*****

*****

*****

*****

*****

*****

*****

5. Piping (Material) (mark all that apply)

Bare Steel

Galvanized Steel

Fiberglass Reinforced Plastic

Copper

Cathodically Protected

Double Walled

Secondary Containment

Unknown

Other, Please Specify

*****

*****

*****

*****

*****

*****

*****

*****

6. Piping (Type) (mark all that apply)

Suction: no valve at tank

Suction: valve at tank

Pressure

Gravity Feed

Has piping been repaired?

*****

*****

*****

*****

*****

EPA Form 7530-1 (Rev. 8-94) Electronic and Paper versions acceptable. Page 3 of 5

Previous editions may be used while supplies last.
United States

Environmental Protection Agency

Washington, DC 20460

Form Approved.

OMB No. 2050-0068

Approval expires 3/31/98

Notification for Underground Storage Tanks

Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 

7. Substance Currently or Last Stored in Greatest

Quantity by Volume

Gasoline

Diesel

Gasohol

Kerosene

Heating Oil

Used Oil

Other

Please Specify

*****

*****

*****

*****

*****

*****

*****

Hazardous Substance

CERCLA name and/or

CAS number

*****

Mixture of Substances

Please Specify

*****

X. TANKS OUT OF USE, OR CHANGE IN SERVICE

1. Closing of Tank

A. Estimated date last used

(mo./day/year)

B. Estimated date tank closed

(mo./day/year)

C. Tank was removed from ground

D. Tank was closed in ground

E. Tank filled with inert material

Describe

F. Change in service

*****

*****

*****

*****

2. Site Assessment Completed *****

Evidence of a leak detected *****

EPA Form 7530-1 (Rev. 8-94) Electronic and Paper versions acceptable. Page 4 of 5

Previous editions may be used while supplies last.
United States

Environmental Protection Agency

Washington, DC 20460

Form Approved.

OMB No. 2050-0068

Approval expires 3/31/98

Notification for Underground Storage Tanks

XI. CERTIFICATION OF COMPLIANCE (COMPLETE FOR ALL NEW AND UPGRADED TANKS AT THIS LOCATION)

Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 

1. Installation

A. Installer certified by tank and piping

manufacturers

B. Installer certified or licensed by the implementing

agency

C. Installation inspected by a registered 

engineer

D. Installation inspected and approved by

implementing agency

E. Manufacturer’s installation checklists have been

completed

F. Another method allowed by State agency. Please

specify.

*****

*****

*****

*****

*****

*****

2. Release Detection (Mark all that apply) TANK PIPING TANK PIPING TANK PIPING TANK PIPING TANK PIPING

A. Manual tank gauging

B. Tank tightness testing

C. Inventory Controls *

D. Automatic tank gauging

E. Vapor monitoring

F. Groundwater monitoring

G. Verify monitoring/secondary containment

H. Automatic line leak detectors

I. Line tightness testing

J. Other method allowed by implementing agency.

*

*

*

*

*

*

*

*

*

* * * * * * * * *

* * * * * * * * *

* * * * * * * * *

* * * * * * * * *

*********

*********

*********

*********

*********

*********

Please specify

3. Spill and Overfill Protection

A. Overfill device installed

B. Spill device installed

*****

*****

OATH: I certify the information concerning installation that is provided in section XI is true to the best of my belief and knowledge.

Installer: Name Signature Date

 

Position Company

EPA Form 7530-1 (Rev. 8-94) Electronic and Paper versions acceptable. Page 5 of 5

Previous editions may be used while supplies last.