## Appendix I t**o Part 280** United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **f or Underground Storage Tanks**  Implementing Agency Name A nd Address: 

### IMPLEMENTING AGENCY USE ONLY ID NUMBER: DATE RECEIVED: 

### TYPE OF NOTIFICA

**TION** DATE ENTERED INTO COMPUTER: 

##  A. NEWFACILITY OR ONE -TIME NOTIFICATION (previously deferred system) 

##  B. AMENDED 

##  C. CLOSURE OR CHANGE - IN SERVICE DATA ENTRY CLERK INITIALS: OW NER WAS CONTACTED TO CLARIFY RESPONSES, COMMENTS: _____ Number of tanks at facility _____ Number of continuation sheets attached **What USTs A re 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 A re Covered**  below). This includes UST systems with field -constructed tanks and airport hydrant fuel distribution systems. **What Tanks A re Excluded From Notification (see § 280.10 and § 280.12)?**   Tanks removed from the ground before May 8, 1986;  Farm or residential tanks of 1,100 gallons or less capacity storing motor fuel for noncommercial purposes;  Tanks storing heating oil for use on the premises where stored;  Septic tanks;  Certain pipeline facilities regulated under chapters 601 and 603 of Title 49;  Surface impoundments, pits, ponds, or lagoons;  Storm water or wastewater collection systems;  Flow-through process tanks;  Liquid traps or associated gathering lines directly related to oil or gas production and gat hering operations;  Tanks on or above the floor of underground areas, such as basements or tunnels;  Tanks with a capacity of 110 gallons or less;  Wa stewater treatment tank systems;  UST systems containing radioactive material that are regulated under the Atomic Energy Act of 1954;  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 A re Covered?**  The notification re quirements 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 un der Subtitle C of the Resource Conservation and Recovery Act

. **When A** **nd 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 im plementing 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 A**ND GENERA L INFORM**  **AT ION**  Please **ty pe 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**  **aft er 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 A** **ct (SWDA ), as amended.**  **Who Must Notify ?**  40 CFR part 280, as amended , requires owners of USTs that store regulated substances (unless exempted) to notify im plementing agencies of the existence of their USTs. Owner is defined as:  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  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 [DATE of REG] must submit a one -time notification of existence by [ ENTER DATE three years after REG] . Owners of UST systems with field -constructed tanks and airport hydrant fuel distribution systems brought into use after [DATE of REG] are considered new facilities an d 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, O r Other Entity) If required by implementing agency, give the geographic location of USTs either in decimal degrees , or degrees, minutes, and seconds. Example: Latitude : 36.12348 0 (or 36  7 ' 24.4 " ) , Longitude : - 106.549876 (or - 106  32 ' 59.6 " )

**Latitude ________________ Longitude**

**________________** Street Address County Facility Name O r Company Site Identifier, As A pplicable  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**EPA Form**  **7530 -**  **1 (Rev. 6 -** **2015 )**  Electronic and paper versions acceptable. Page 2 of 6

Previous editions m ay be used while supplies last. United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **F or Underground Storage Tanks**  **III. TYPE OF OWNER IV. INDIAN COUNTRY**  

#  Federal Government 

#  State Government 

#  Commercial 

#  Tribal Government 

#  Local Government 

#  Private U STs 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 O r Airline 

#  Gas Station 

#  Trucking O r 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):



### V **II. FINANCIAL RESPONSIBILITY** 

#  I have met the financial responsibility requirements (in accordance with 40 CFR p art 280 Subpart H) by using the following mechanisms: ( c heck a ll t hat a pply) 

#  Bond Rating Test 

#  Local Government Financial Test 

#  Surety Bond 

#  Commercial Insurance 

#  Risk Retention Group 

#  Trust Fund 

#  Guarantee 

#  Self- i nsurance (Financial Test) 

#  Other Method (describe here) 

#  Letter Of Credit 

#  State Fund 

## ___________________________ 

#  I do not have to meet financial responsibility requirements because 40 CFR p art 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 A ct Notice**  The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. 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 co llection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Penns ylvania Ave., NW , W ashington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.**EPA Form**  **7530 -**  **1 (Rev. 6 -** **2015 )**  Electronic and paper versions acceptable. Page 3 of 6

Previous editions m ay be used while supplies last. United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **F or 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 O** **f Tank** (check only one) Currently In Use Temporarily Closed Permanently Closed 

## 

  

  

  

  

  **2 .**  **Date O** **f Installation** (m onth/year) **3 .**  **Estimated Total Capacity** (gallons) **4 .**  **Tank A**

**ttributes** ( check all that apply)

Asphalt Coated O r 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 c lad with noncorrodible m aterial) 

##      Concrete 

##      Fiberglass Reinforced Plastic 

##      Noncorrodible Tank Jacket 

##     

Lined Interior 

##      Excavation Liner 

##      Double W alled 

##      Manifolded 

##      Compartmentalized 

##      Field -constructed 

##      Double W alled 

##      Unknown 

##      Other, Specify H ere 

## ___________

___________ ___________

___________ ___________

___________ ___________

___________ ___________

___________ C heck Box If Tank Has Ever Been Repaired 

##      **5 .**  **Overfill Protection Installed** ( check all that apply) Automatic Shutoff 

#      Flow Restrictor 

#      High - level Alarm 

#      Other, Specify H ere



## ___________ ___________ ___________ ___________ ___________ **6 .**  **Spill Prevention**  **Installed** 

#      Double W alled 

#     **EPA Form**  **7530 -**  **1 (Rev. 6 -** **2015 )**  Electronic and paper versions acceptable. Page 4 of 6

Previous editions m ay be used while supplies last. United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **F or Underground Storage Tanks**  Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. **7 .**  **Piping A**

**ttributes** ( check all that apply) Bare Steel 

##      Galvanized Steel 

##      Fiberglass Reinforced Plastic 

##     

Flexible Plastic 

##      Copper 

##      Cathodically Protected (impressed current) 

##      Cathodically Protected (sacrificial anodes) 

##      Double W alled 

##      Secondary Containment 

##      Airport Hydrant Piping 

##     

Unknown 

##      Other, Specify H ere 

## ___________

___________ ___________

___________ ___________

___________ ___________

___________ ___________

___________ **8 .**  **Piping Delivery**

**Ty pe**  ( 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) Gasoline (containing ≤ 10% ethanol) 

#      Diesel 

#      Biodiesel 

#      Kerosene 

#      Heating Oil 

#      Used Oil 

#      Gasoline Containing >10% E thanol (specify amount of ethanol )



## ___________ ___________ ___________ ___________ ___________ Diesel Containing >20% B iodiesel (specify amount of biodiesel )



## ___________ ___________ ___________ ___________ ___________

Other, specify here



## ___________ ___________ ___________ ___________ ___________ Hazardous Substance 

#      CERCLA Name O r CAS Number



## ___________ ___________ ___________ ___________ ___________

Mixture Of Substances 

#      Please S pecify S ubstances H ere



## ___________ ___________ ___________ ___________ ___________**EPA Form**  **7530 -**  **1 (Rev. 6 -** **2015 )**  Electronic and paper versions acceptable. Page 5 of 6

Previous editions m ay be used while supplies last. United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **F or 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 T ightness Testing 

#      Inventory Control 

#      Automatic Tank G auging 

#           Vapor M onitoring 

#           Groundwater M onitoring 

#           Interstitial M onitoring (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, S pecify H ere



## ___________ ___________ ___________ ___________ ___________ **X. CLOSURE OR CHANGE IN SERVICE 1**  **. Closure**  **O r Change**  **I n Service**  Estimated Date The UST Was Last Used For Storing Regulated S ubstances

(month/day/year) 

## ___________ ___________ ___________ ___________ ___________ Check Box If This Is A Change In S ervice (i.e., Change of storage to a non regulated substance) 

#     
**2 .**  **Tank Closure**

Estimated Date Tank C losed

(month/day/year)



## ___________ ___________ ___________ ___________ ___________ ( c heck all that apply below) Tank Rem oved From G round 

#      Tank C losed In G round 

#      Tank Filled With Inert M aterial 

#      De scribe The Inert Fill Material H ere



## ___________ ___________ ___________ ___________ ___________ **3 .**  **Site A ssessment**  Check Box If The Site Assessment Was Completed 

#      Check B ox If Evidence Of A Release

Was D etected 

#      Other, Specify H ere



## ___________ ___________ ___________ ___________ ___________**EPA Form**  **7530 -**  **1 (Rev. 6 -** **2015 )**  Electronic and paper versions acceptable. Page 6 of 6

Previous editions m ay be used while supplies last. United States 

## Environmental Protection A**gency**

Washington, DC 20460 Approval expires xx/xx/xx OMB No.2050 -0068 

## Notification **F or Underground Storage Tanks**  Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 

### XI. **CERTIFICATION OF INSTALLATION ( Complete**  **F or**  **UST S ys** **tems I**  **nstalled A** **fter D**  **ecember 22, 1988**  **A nd**  **F or**  **A irport**  **H yd**  **rant D**  **istribution S**  **ys tems**  **A nd**  **F ield**  **- C**  **onstructed USTs I**  **nstalled A** **fter [DATE OF REG]**  **) Installer Of Tank A** **nd Piping** ( c heck a ll t hat a pply) Installe r Certified By Tank And Piping M anufacturers 

#      Installer C ertified O r L icense d B y The

I mplementing Agency 

#      Installation Inspected By A Registered E ngineer 

#      Installation Inspected A nd Approved By

Implementing Agency 

#      Manufacturer’s Installation Checklists

Have Been Com pleted 

#      Another Method Allowed By Implementing Agency 

#      S pecify Other Method H ere



## ___________ ___________ ___________ ___________ ___________ **Signature O** **f UST Installer Certify ing Proper Installation**  **O f UST Sy** **stem**

___________________________

Name ___________________________ Signature _________________ Date

___________________________

Position ___________________________ Company