30-Day Notice For Underground Storage Tanks

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UST ID #: __________
30-D
N
AY
OTICE
County: __________
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
This form provides Ecology 30-days’ advanced notice for the following
projects, as required by Chapter 173-360 WAC.
Instructions are found on the back page.
Please  the appropriate box:
Intent to Install
Intent to Close
Change-in-Service
I. S
I
II. O
/O
I
ITE
NFORMATION
WNER
PERATOR
NFORMATION
Tag or UBI # (if applicable):
Owner/Operator Name:
UST ID # (if applicable):
Business Name:
Site Name:
Mailing Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Phone:
Email:
III. C
S
P
(
)
ERTIFIED
ERVICE
ROVIDER
S
Check the appropriate boxes. If more than one service provider is required
for this project, fill out both sections.
Note: Individuals performing UST services MUST be ICC-certified or have passed
another qualifying exam approved by the Department of Ecology.
1)
Installer
Decommissioner
Site Assessor
Company Name:
Certification Type:
Service Provider Name:
Cert. No.:
Exp. Date:
Provider Phone:
Provider Email:
2)
Installer
Decommissioner
Site Assessor
Company Name:
Certification Type:
Service Provider Name:
Cert. No.:
Exp. Date:
Provider Phone:
Provider Email:
IV. T
I
ANK
NFORMATION
D
P
ATE
ROJECT IS
S
T
UBSTANCE
ANK
T
ID
E
C
ANK
XPECTED TO
OMMENTS
S
C
TORED
APACITY
B
EGIN

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