Closure Authorization For Hazardous Substance Underground Storage Tanks printable pdf download

DPW USE ONLY:

FORM VALID JULY 1, 2016 TO JUNE 30, 2017

SITE-FILE NO. ___________________________________

CLOSURE AUTHORIZATION FOR HAZARDOUS

SUBSTANCE UNDERGROUND STORAGE TANKS

APP NO. _____________________________ AREA_____

COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS (DPW)

Environmental Programs Division

CHECK [ ]

CASH [ ]

OTHER [ ]

900 South Fremont Avenue, 3

Floor Annex Building

Alhambra, CA 91803-1331

FEE $ _____________________

Phone Number (626) 458-3517, Fax Number (626) 458-3569

CLOSURE REQUESTED:

PERMANENT, UST REMOVAL

PERMANENT, UST CLOSURE IN-PLACE - Attach Justification Statement

TEMPORARY CLOSURE

OTHER (ONLY PIPING, UNDER DISPENSER CONTAINMENT, ETC), EXPLAIN: ___________________________________________

ATTACH PLOT PLAN Show existing tanks, piping and dispenser locations, etc. (to scale).

FACILITY California Environmental Reporting System (CERS) ID: ___________________ DATE INFORMATION SUBMITTED TO CERS: _____________

HOW MANY UNDERGROUND STORAGE TANKS WILL REMAIN AFTER THIS CLOSURE? __________

EXISTING HSUSP NUMBER:_______________

Who is closing the UST(s)?

UST OWNER/OPERATOR

CONTRACTOR

Email address of UST owner/operator or recipient: ____________________________________________________________________________________

FACILITY TO BE CLOSED (VERIFICATION FOR NOTIFICATIONS):

Facility Name: _____________________________________________________________________ Phone: ________________________________

Facility Address: ________________________________________________ City: ________________________________ Zip: __________________

Tank Owner/Contact: _______________________________________________________ Title: __________________________________________

Contractor Name: _________________________________________________________________ Phone: __________________________________

Contractor License No.: ______________________________________________________ Class(s): _______________________________________

***Contractors Shall Be Hazardous Substance Removal Certified “HAZ” per California Business & Professions Code Division 3, Chapter 9, Article 4, §7058.7 (e)***

NUMBER OF UST’s

UST ID NO.

CAPACITY

SUBSTANCES STORED

CLOSURE FEE

TO BE CLOSED

(DPW USE ONLY)

GALLONS

(PAST/PRESENT)

$ 810.00

$ 996.00

$1,182.00

$1,368.00

$1,554.00

6 (+ ATTACH LIST)

$624.00 + $186.00/PER TANK =

Closure of Underground Storage Tanks (USTs) shall be in compliance with Los Angeles County Code Title 11, Division 4

COMPLETE SURVEY:

YES

Has an unauthorized release ever occurred at this site? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Has a structural repair ever been made to these underground storage tanks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Will new underground storage tanks be installed after closure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Will any wells, including monitoring wells, be abandoned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NOTICE: CONTAMINATED TANKS AND RESIDUES IN TANKS TO BE CLOSED, MAY BE HAZARDOUS WASTE WHICH MUST BE TRANSPORTED

AND DISPOSED OF PURSUANT TO CALIFORNIA HEALTH AND SAFETY CODE DIVISON 20, CHAPTER 6.5 AND MUST BE REPORTED IN THE

CLOSURE REPORT. FAILURE TO COMPLY MAY BE PROSECUTED AS A FELONY VIOLATION.

By signature below, you certify that all statements and disclosures above are true and correct and that you have read and agree to abide by this authorization and

all conditions and limitations on the back and attached:

Authorization Recipient (Print Name) ____________________________________________________

Phone ________________________________

Recipient’s Signature ________________________________________________________________

Date __________________________________

Recipient is:

UST Owner

UST Operator

Contractor

Written authorization is required for submittals made on behalf of owner/operator.

TO BE COMPLETED BY THE DEPARTMENT OF PUBLIC WORKS

PURSUANT TO SECTION 11.80.070B, LOS ANGELES COUNTY CODE, PERMISSION IS HEREBY GRANTED TO PROCEED WITH THE CLOSURE