                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               OMB No.2050-0068
                                                                               
                  Notification for Underground Storage Tanks
Implementing Agency Name And Address:
                         IMPLEMENTING AGENCY USE ONLY

ID NUMBER:


DATE RECEIVED:

                             TYPE OF NOTIFICATION

DATE ENTERED INTO COMPUTER:
 A. NEW FACILITY OR ONE-TIME NOTIFICATION (previously deferred system)
 B. AMENDED
 C. CLOSURE OR CHANGE-IN-SERVICE 
DATA ENTRY CLERK INITIALS:



OWNER WAS CONTACTED TO CLARIFY RESPONSES, COMMENTS:
_____  Number of tanks at facility
_____  Number of continuation sheets attached
What USTs Are 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 Are Covered below).  This includes UST systems with field-constructed tanks and airport hydrant fuel distribution systems.
What Tanks Are 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 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;
  Wastewater 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 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, with the exception of those substances regulated as hazardous waste under Subtitle C of the Resource Conservation and Recovery Act.
When And 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 implementing 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 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 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 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 Solid Waste Disposal Act (SWDA), as amended.
Who Must Notify?  40 CFR part 280, as amended, requires owners of USTs that store regulated substances (unless exempted) to notify implementing 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 and 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, Or Other Entity)
If required by implementing agency, give the geographic location of USTs either in decimal degrees, or degrees, minutes, and seconds.  Example: Latitude: 36.123480 (or 36 7' 24.4"),  Longitude: -106.549876 (or -106 32' 59.6")
	Latitude ________________     Longitude ________________
Street Address

County
Facility Name Or Company Site Identifier, As Applicable

   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
                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               OMB No.2050-0068
                                                                               
                  Notification For Underground Storage Tanks
                              III. TYPE OF OWNER
                              IV. INDIAN COUNTRY
	Federal 
        Government 
 State
        Government 
 Commercial
  Tribal
        Government 
  Local
        Government 
 Private

USTs 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 Or Airline 
 Gas Station
 Trucking Or 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):
VII. FINANCIAL RESPONSIBILITY 
 I have met the financial responsibility requirements (in accordance with 40 CFR part 280 Subpart H) by using the following mechanisms:
(check all that apply)
 Bond Rating Test 
 Local Government Financial Test 
 Surety Bond
 Commercial Insurance 
 Risk Retention Group
 Trust Fund
 Guarantee
 Self-insurance (Financial Test)
 Other Method (describe here)
 Letter Of Credit
 State Fund 
___________________________
 I do not have to meet financial responsibility requirements because 40 CFR part 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 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.
                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               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
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
2. Date Of Installation (month/year)





3. Estimated Total Capacity (gallons)





4. Tank Attributes
(check all that apply)
                                       
                                       
                                       
                                       
                                       
                                                   Asphalt Coated Or 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 clad with noncorrodible material)
                                       
                                       
                                       
                                       
                                       
                                                                       Concrete
                                       
                                       
                                       
                                       
                                       
                                                  Fiberglass Reinforced Plastic
                                       
                                       
                                       
                                       
                                       
                                                      Noncorrodible Tank Jacket
                                       
                                       
                                       
                                       
                                       
                                                                 Lined Interior
                                       
                                       
                                       
                                       
                                       
                                                               Excavation Liner
                                       
                                       
                                       
                                       
                                       
                                                                  Double Walled
                                       
                                       
                                       
                                       
                                       
                                                                     Manifolded
                                       
                                       
                                       
                                       
                                       
                                                              Compartmentalized
                                       
                                       
                                       
                                       
                                       
                                                              Field-constructed
                                       
                                       
                                       
                                       
                                       
                                                                  Double Walled
                                       
                                       
                                       
                                       
                                       
                                                                        Unknown
                                       
                                       
                                       
                                       
                                       
                                                            Other, Specify Here
___________
                                  ___________
___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                       Check Box If Tank Has Ever Been Repaired
                                       
                                       
                                       
                                       
                                       
5. Overfill Protection Installed
(check all that apply)
                                       
                                       
                                       
                                       
                                       
                                                             Automatic Shutoff 
                                       
                                       
                                       
                                       
                                       
                                                                Flow Restrictor
                                       
                                       
                                       
                                       
                                       
                                                               High-level Alarm
                                       
                                       
                                       
                                       
                                       
                                                            Other, Specify Here
___________
___________
                                  ___________
                                  ___________
                                  ___________
6. Spill Prevention Installed
                                       
                                       
                                       
                                       
                                       
                                                                  Double Walled
                                       
                                       
                                       
                                       
                                       
                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               OMB No.2050-0068
                                                                               
                  Notification For Underground Storage Tanks
Tank Identification Number
Tank No.
Tank No.
Tank No.
Tank No.
Tank No.
7. Piping Attributes 
(check all that apply)
                                       
                                       
                                       
                                       
                                       
                                                                     Bare Steel
                                       
                                       
                                       
                                       
                                       
                                                               Galvanized Steel
                                       
                                       
                                       
                                       
                                       
                                                  Fiberglass Reinforced Plastic
                                       
                                       
                                       
                                       
                                       
                                                               Flexible Plastic
                                       
                                       
                                       
                                       
                                       
                                                                         Copper
                                       
                                       
                                       
                                       
                                       
                                                        Cathodically Protected 
                                                            (impressed current)
                                       
                                       
                                       
                                       
                                       
                                                        Cathodically Protected 
                                                           (sacrificial anodes)
                                       
                                       
                                       
                                       
                                       
                                                                  Double Walled
                                       
                                       
                                       
                                       
                                       
                                                          Secondary Containment
                                       
                                       
                                       
                                       
                                       
                                                         Airport Hydrant Piping
                                       
                                       
                                       
                                       
                                       
                                                                        Unknown
                                       
                                       
                                       
                                       
                                       
                                                            Other, Specify Here
___________
                                  ___________
___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
8. Piping Delivery Type 
(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% Ethanol (specify amount of ethanol)
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                            Diesel Containing >20% Biodiesel
                                                  (specify amount of biodiesel)
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                                            Other, specify here
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                                            Hazardous Substance
                                       
                                       
                                       
                                       
                                       
                                                      CERCLA Name Or CAS Number
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                                          Mixture Of Substances
                                       
                                       
                                       
                                       
                                       
                                                 Please Specify Substances Here
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               OMB No.2050-0068
                                                                               
                                                                               
                  Notification For 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 Tightness Testing
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                                              Inventory Control
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                                         Automatic Tank Gauging
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                                               Vapor Monitoring
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                                         Groundwater Monitoring
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                        Interstitial Monitoring 
(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, Specify Here
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
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
                         (i.e., Change of storage to a non-regulated substance)
                                       
                                       
                                       
                                       
                                       
2. Tank Closure 
                                       
                                       
                                       
                                       
                                       
                                    Estimated Date Tank Closed (month/day/year)
___________
___________
                                  ___________
                                  ___________
                                  ___________
                                                   (check all that apply below)
                                       
                                       
                                       
                                       
                                       
                                                       Tank Removed From Ground
                                       
                                       
                                       
                                       
                                       
                                                          Tank Closed In Ground
                                       
                                       
                                       
                                       
                                       
                                                Tank Filled With Inert Material
                                       
                                       
                                       
                                       
                                       
                                          Describe The Inert Fill Material Here
___________
___________
                                  ___________
                                  ___________
                                  ___________
3. Site Assessment
                                       
                                       
                                       
                                       
                                       
                                 Check Box If The Site Assessment Was Completed
                                       
                                       
                                       
                                       
                                       
                                Check Box If Evidence Of A Release Was Detected
                                       
                                       
                                       
                                       
                                       
                                                            Other, Specify Here
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                  ___________
                                 United States
                        Environmental Protection Agency
                             Washington, DC 20460
                                                      Approval expires xx/xx/xx
                                                               OMB No.2050-0068
                                                                               
                  Notification For Underground Storage Tanks
Tank Identification Number
Tank No.
Tank No.
Tank No.
Tank No.
Tank No.
XI. CERTIFICATION OF INSTALLATION (Complete For UST Systems Installed After December 22, 1988 And For Airport Hydrant Distribution Systems And Field-Constructed USTs Installed After [DATE OF REG])
Installer Of Tank And Piping 
(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 Implementing Agency
                                       
                                       
                                       
                                       
                                       
                                                      Specify Other Method Here
___________
___________
                                  ___________
                                  ___________
                                  ___________
Signature Of UST Installer Certifying Proper Installation Of UST System


                          ___________________________
                                     Name



                          ___________________________
                                   Signature



                               _________________
                                     Date



                          ___________________________
                                   Position



                          ___________________________
                                    Company



