Underground Storage Tank System Closure Permit Application Form Page 2
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2UST System Closure Permit Application - p. 2 of 2 Tank Site Address:
Tank Size
Substance(s) Previously
Tank Size
Substance(s) Previously
10.
(gallons)
Contained
(gallons)
Contained
Tank 1:
Tank 2:
Tank 3:
Tank 4:
Tank 5:
Tank 6:
If the facility does not have a current submitted Hazardous Materials Business Plan (HMBP) which includes these tanks, attach an 8-
1/2” x 11” plot plan of the tanks to be closed. Indicate the nearest cross street to the facility, buildings immediately adjacent to the
tanks, location(s) of tanks to be closed, and location of nearby utilities.
UST OWNER: I am the owner of the tank(s) listed above. I am aware of the pending closure and hereby authorize
representatives of the agencies overseeing closure activities to enter upon the mentioned property for inspection purposes.
UST Owner Name (Print)
UST Owner Signature
Date
APPLICANT: I certify that I have read the Unidocs Underground Storage Tank System and Sump Closure Requirements
(UN-002) and declare that the above information is correct to the best of my knowledge. I agree to comply with all applicable
city and county ordinances and state laws relating to management of hazardous materials/wastes.
Applicant/Agent’s Name (Print)
Applicant/Agent’s Signature
Date
These boxes are for Unified Program Agency Use Only
THIS APPROVAL CONSTITUTES A PERMIT FOR REMOVAL OF THE ABOVE LISTED TANKS
Agency: _______________________________________________________________________ Date: _____________________
Print Name: ___________________________ Sign Name: ___________________________ Permit/Project No.: _____________
This permit expires 6 months from the date of approval. If tanks have not been closed within 6 months, a new closure permit
application and fees may be required. Inspections must be scheduled at least 2 working days in advance.
Laboratory analyses shall test for the following in accordance with the UST System Closure Sampling and Laboratory Analyses Requirements (UN-078)
EDB & EDC
Organic Lead
HEM (EPA 9071B)
Other (Specify)
TPH
BTEX, Ethanol, Naphthalene
(EPA 8260B/C)
(EPA 8081)
VOCs Full Scan (EPA 8260B)
TPH Gasoline or TPH
& Fuel Oxygenates (DIPE,
Cl HC Full Scan (EPA 8260B)
GRO (EPA 8015 or
ETBE, MTBE, TAME, &
PCBs (EPA 8082A)
8260B/C)
TBA)
TPH Diesel (EPA 8015)
SVOCs including PAHs (EPA 8270)
(EPA 8260B/C)
TPH Kerosene EPA 8015)
Metals (Cd, Cr, Pb, Ni & Zn) (EPA 6010B)
Tank 1
Tank 2
Tank 3
Tank 4
Tank 5
Tank 6
Additional analyses may be required by inspector in field.
THIS CERTIFIES THAT ALL TANK SYSTEM CLOSURE ACTIVITIES ARE COMPLETE*
Agency: _______________________________________________________________ Date: _____________________
Print Name: ________________________________________ Sign Name: ___________________________________
* If contamination of any detectable concentration is found, contact the leaking underground storage tank Local Oversight
Program (LOP) and/or Regional Water Quality Control Board for cleanup and/or remediation requirements.
UN-003
2/2 - Rev. 12/16/15
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