Document ID: EPA-HQ-UST-2004-0001-0004
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2004-09-21T04:00Z

United
States
Environmental
Protection
Agency
Washington,
DC
20460
OMB
No.
2050­
0068
Approval
expires:
xx/
xx/
xxxx
Notification
for
Underground
Storage
Tanks
State
Agency
Name
and
Address:
STATE
USE
ONLY
ID
NUMBER:

DATE
RECEIVED:

TYPE
OF
NOTIFICATION
DATE
ENTERED
INTO
COMPUTER:

G
A.
NEW
FACILITY
G
B.
AMENDED
G
C.
CLOSURE
DATA
ENTRY
CLERK
INITIALS:

_____
Number
of
tanks
at
facility
_____
Number
of
continuation
sheets
attached
OWNER
WAS
CONTACTED
TO
CLARIFY
RESPONSES,
COMMENTS:

INSTRUCTIONS
AND
GENERAL
INFORMATION
Please
type
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
5
and
use
them
for
additional
tanks.

The
primary
purpose
of
this
notification
program
is
to
locate
and
evaluate
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
after
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
Resource
Conservation
and
Recovery
Act
(
RCRA),
as
amended.

Who
Must
Notify?
Section
9002
of
RCRA,
as
amended,
requires
owners
of
USTs
that
store
regulated
substances
(
unless
exempted)
to
notify
designated
State
or
local
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,
if
the
State
so
requires,
any
facility
that
has
made
any
changes
to
facility
information
or
UST
system
status,
must
submit
a
notification
form
(
only
amended
information
needs
to
be
included).

What
USTs
Are
Included?
An
UST
system
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.
Regulated
USTs
store
petroleum
or
hazardous
substances
(
see
the
following
"
What
Substances
Are
Covered").
What
Tanks
Are
Excluded
From
Notification?

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;
°
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;
°
Surface
impoundments,
pits,
ponds,
or
lagoons;
°
Storm
water
or
waste
water
collection
systems;
°
Flow­
through
process
tanks;
°
Liquid
traps
or
associated
gathering
lines
directly
related
to
oil
or
gas
production
and
gathering
operations;
°
Tanks
on
or
above
the
floor
of
underground
areas,
such
as
basements
or
tunnels;
°
Tanks
with
a
capacity
of
110
gallons
or
less.

What
Substances
Are
Covered?
The
notification
requirements
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
(
CERCLA),
with
the
exception
of
those
substances
regulated
as
hazardous
waste
under
Subtitle
C
of
RCRA.

Where
To
Notify?
Send
completed
forms
to:

When
To
Notify?
1.
Owners
of
USTs
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
USTs
into
use
after
May
8,
1986,
must
notify
within
30
days
of
bringing
the
UST
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
$
11,000
for
each
tank
for
which
notification
is
not
given
or
for
which
false
information
is
given.

I.
OWNERSHIP
OF
UST(
s)
II.
LOCATION
OF
UST(
s)

Owner
Name
(
Corporation,
Individual,
Public
Agency,
or
Other
Entity)
If
required
by
State,
give
the
geographic
location
of
USTs
by
degrees,
minutes,
and
seconds.
Example:
Latitude
42

36'
12"
N,
Longitude
85

24'
17"
W
Latitude
________________
Longitude
________________

Street
Address
Facility
Name
or
Company
Site
Identifier,
as
applicable
County
Q
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.
11­
98)
Electronic
and
paper
versions
acceptable.
Page
1
of
5
Previous
editions
may
be
used
while
supplies
last.
G
G
United
States
Environmental
Protection
Agency
Washington,
DC
20460
Form
Approved.
OMB
No.
2050­
0068
Notification
for
Underground
Storage
Tanks
III.
TYPE
OF
OWNER
IV.
INDIAN
COUNTRY
G
Federal
Government
G
State
Government
G
Commercial
G
Local
Government
G
Private
USTs
are
located
on
land
within
an
Indian
Reservation
or
on
trust
lands
outside
reservation
boundaries.

USTs
are
owned
by
a
Native
American
nation
or
tribe.
Tribe
or
Nation
where
USTs
are
located:

V.
TYPE
OF
FACILITY
G
Gas
Station
G
Petroleum
Distributor
G
Air
Taxi
(
Airline)

G
Aircraft
Owner
G
Auto
Dealership
G
Railroad
G
Federal
­
Non­
Military
G
Federal
­
Military
G
Industrial
G
Contractor
G
Trucking/
Transport
G
Utilities
G
Residential
G
Farm
G
Other
(
Explain)
_____________________________

VI.
CONTACT
PERSON
IN
CHARGE
OF
TANKS
Name:
Job
Title:
Address:
Phone
Number
(
Include
Area
Code):

VII.
FINANCIAL
RESPONSIBILITY
GI
have
met
the
financial
responsibility
requirements
(
in
accordance
with
40
CFR
Subpart
H)
by
using
the
following
mechanisms:

Check
All
that
Apply
G
Self
Insurance
G
Commercial
Insurance
G
Risk
Retention
Group
G
Local
Government
Financial
Test
G
Guarantee
G
Surety
Bond
G
Letter
of
Credit
G
Bond
Rating
Test
G
State
Funds
G
Trust
Fund
G
Other
Method
(
describe
here)

______________________________________

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
Act
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
collection
techniques
to
the
Director,
Collection
Strategies
Division,
U.
S.
Environmental
Protection
Agency
(
2822T),
1200
Pennsylvania
Ave.,
NW,
Washington,
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.
11­
98)
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
Notification
for
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
of
Tank
(
check
only
one)
Currently
In
Use
Temporarily
Closed
Permanently
Closed
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
2.
Date
of
Installation
(
month/
year)

3.
Estimated
Total
Capacity
(
gallons)

4.
Material
of
Construction
(
check
all
that
apply)

Asphalt
Coated
or
Bare
Steel
Cathodically
Protected
Steel
Coated
and
Cathodically
Protected
Steel
Composite
(
Steel
Clad
with
Fiberglass)

Fiberglass
Reinforced
Plastic
Lined
Interior
Excavation
Liner
Double
Walled
Polyethylene
Tank
Jacket
Concrete
Unknown
If
Other,
please
specify
here
Check
box
if
tank
has
ever
been
repaired
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
5.
Piping
Material
(
check
all
that
apply)
Bare
Steel
Galvanized
Steel
Fiberglass
Reinforced
Plastic
Copper
Cathodically
Protected
Double
Walled
Secondary
Containment
Unknown
Other,
please
specify
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
6.
Piping
Type
"
Safe"
Suction
(
no
valve
at
tank)

(
Check
all
that
apply)
"
U.
S."
Suction
(
valve
at
tank)

Pressure
Gravity
Feed
Check
box
if
piping
has
ever
been
repaired
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
EPA
Form
7530­
1
(
Rev.
11­
98)
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
Notification
for
Underground
Storage
Tanks
Tank
Identification
Number
Tank
No.
Tank
No.
Tank
No.
Tank
No.
Tank
No.

7.
Substance
Currently
Stored
(
or
last
Gasoline
stored
in
the
case
of
closed
tanks)
Diesel
(
Check
all
that
apply)
Gasohol
Kerosene
Heating
Oil
Used
Oil
If
Other,
please
specify
here
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
Hazardous
Substance
CERCLA
name
and/
or
CAS
number
G
G
G
G
G
Mixture
of
Substances
Please
specify
here
G
G
G
G
G
8.
Release
Detection
(
check
all
that
apply)

Manual
tank
gauging
Tank
tightness
testing
Inventory
Control
Automatic
tank
gauging
Vapor
monitoring
Groundwater
monitoring
Interstitial
monitoring
Automatic
line
leak
detectors
Line
tightness
testing
No
release
detection
required
(
such
as
some
types
of
suction
piping,
emergency
generator
tanks
or
field
constructed
tanks)

Other
method
allowed
by
implementing
agency
(
such
as
SIR)
TANK
G
G
G
G
G
G
G
G
G
PIPE
G
G
G
G
G
G
G
G
G
G
G
TANK
G
G
G
G
G
G
G
G
G
PIPE
G
G
G
G
G
G
G
G
G
G
G
TANK
G
G
G
G
G
G
G
G
G
PIPE
G
G
G
G
G
G
G
G
G
G
G
TANK
G
G
G
G
G
G
G
G
G
PIPE
G
G
G
G
G
G
G
G
G
G
G
TANK
G
G
G
G
G
G
G
G
G
PIPE
G
G
G
G
G
G
G
G
G
G
G
Please
specify
other
method
here
9.
Spill
and
Overfill
Protection
Overfill
device
installed
Spill
device
installed
G
G
G
G
G
G
G
G
G
G
EPA
Form
7530­
1
(
Rev.
11­
98)
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
Notification
for
Underground
Storage
Tanks
Tank
Identification
Number
Tank
No.
Tank
No.
Tank
No.
Tank
No.
Tank
No.

X.
CLOSURE
OR
CHANGE
IN
SERVICE
1.
Closure
or
Change
in
Service
Estimated
date
the
UST
was
last
used
for
storing
regulated
substances
(
month/
day/
year)

Check
box
if
this
is
a
change
in
service
G
G
G
G
G
2.
Tank
Closure
Estimated
date
tank
closed
(
month/
day/
year)

(
check
all
that
apply
below)

Tank
was
removed
from
ground
Tank
was
closed
in
ground
Tank
filled
with
inert
material
Describe
the
inert
fill
material
here
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
3.
Site
Assessment
Check
box
if
the
site
assessment
was
completed
Check
box
if
evidence
of
a
leak
was
detected
G
G
G
G
G
G
G
G
G
G
XI.
CERTIFICATION
OF
INSTALLATION
(
COMPLETE
FOR
UST
SYSTEMS
INSTALLED
AFTER
DECEMBER
22,
1988)

Installer
Of
Tank
And
Piping
Must
Check
All
That
Apply:

Installer
certified
by
tank
and
piping
manufacturers
Installer
certified
or
licensed
by
the
implementing
agency
Installation
inspected
by
a
registered
engineer
Installation
inspected
and
approved
by
implementing
agency
Manufacturer's
installation
checklists
have
been
completed
Another
method
allowed
by
State
agency
If
so,
please
specify
here
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
Signature
of
UST
Installer
Certifying
Proper
Installation
of
UST
System
Name
Signature
Date
Position
Company
EPA
Form
7530­
1
(
Rev.
11­
98)
Electronic
and
paper
versions
acceptable.
Page
5
of
5
Previous
editions
may
be
used
while
supplies
last