Mail to:Division of Oil and Public SafetyPage 1 of 4

633 17th Street, Suite 500

Denver, CO80202-3660

E-mail

NOTIFICATION FOR UNDERGROUND STORAGE TANKS

Please choose one:

Amendment of information _____

New facility information _____

Other Information _____

Please type or print all items

I – Owner Information: (who owns the tanks?)
Name:______
Street Address:______
City:______State:______Zip:______Phone:______
II – Owner Type:
Commercial _____Private _____Federal Gov’t. _____
State/Local Gov’t. _____Other _____
III – Billing Information: (where to send the bill for annual registration fees)
Name:______
Address:______
City:______State:______Zip:______Phone:______
IV – Facility Information: (a street address where the tanks are located)
Name:______
Street Address:______
City:______State:______Zip:______Phone:______
Facility Identification Number: (assigned to you by the state, if applicable)______
V – Facility Type:
Aircraft _____ Airline/Air Taxi _____ Auto Dealer _____ Commercial _____ Contractor _____ Farm _____ Federal Military _____
Federal Non Military _____ Gas Station _____ Industrial _____ State/Local Gov’t. _____ Petro Dist. _____ Railroad _____
Residential _____ Trucking/Transporter _____ Utilities _____ Other _____
VI – For tanks on Indian lands:
Owned by Tribe ______Individual ______
VII – Contact person at location:
Name:______Title:______Phone:______
VIII – Financial Responsibility:I have met the financial responsibility requirements of Subpart H, Par 280 of 40 CFR, using these methods:
Self Insured _____ Insurance _____ Risk Detention Group _____ Guarantee _____
Surety Bond _____ Letter of Credit _____ Trust Fund _____ State Fund _____ Other _____
IX – Certification:I certify under the penalty of law that I have examined and am familiar with the information submitted in this and attached documents, and base on my inquiry of the individuals immediately responsible for obtaining information, I believe the submitted information is true, accurate and complete.
Owner / Authorized Representative (please print) ______Title ______
Signature: ______Date: ______

X – Description of UST’s and contents (complete for each tank at this location)Page 2 of 4

Tank No.
1 / Tank No.
2 / Tank No.
3 / Tank No.
4 / Tank No.
5 / Tank No.
6
1. Tank Status
A. Currently in use
B. Temporarily out of use
C. Permanently out of use
2. Date Installed
3. Tank Capacity
4. Material of construction (mark all that apply)
A. Compartment
B. Manifold
C. Asphalt coated / Bare Steel
D. Cathodically protected
E. Composite (steel w/ frp)
F. Concrete
G. Epoxy coated steel
H. FRP / Fiberglass
I. Polyethylene tank jacket
J. Other
K. Unknown
5. Second tank option
A. Double walled
B. Excavation liner
C. Lined interior
D. Has tank been repaired?
6. Piping material (mark all that apply)
A. Bare steel
B. Galvanized steel
C. FRP / Fiberglass
D. Copper
E. Flexible plastic
F. Other
G. Unknown
H. No piping
7. Second piping option
A. Cathodically protected
B. Double walled piping
C. Secondary containment
D. Has piping been repaired?

X – Description of UST’s and contents cont. (complete for each tank at this location)Page 3 of 4

Tank No.
1 / Tank No.
2 / Tank No.
3 / Tank No.
4 / Tank No.
5 / Tank No.
6
8. Piping Type
A. Gravity fed
B. Pressurized
C. Safe suction
D. U.S. Suction
E. Suction
  1. Substance currently or last stored
(Greatest quantity by volume)
A. Diesel
B. Gasohol
C. Gasoline
D. Hazardous substance
1. Principle substance and / or C.A.S. No.
E. Heating Oil
F. Kerosene
G. Mixture
H. Used oil
I. Other
J. Unknown
XI – Closure Information
10. Tank Closure
A. Date last used
B. Date of closure
C. Tank removed from ground
D. Tank closed in place
1. Inert fill
11. Site Assessment
A. Completed
B. Evidence of leak y / n

XII – Certification of Compliance

12. Compliance for all new & upgraded tanks
A. Installers certified by tank & piping manufacturers
B. Installers certified or licensed by State Inspector of Oils
C. Installation inspected by registered engineer
D. Installation inspected & approved by State Inspector of Oils
E. Manufactures’ installation checklists have been completed
F. Another method allowed by State Agency
1. Please Specify

XII – Certification of Compliance cont.Page 4 of 4

13. Release Detection / Tank / Pipe / Tank / Pipe / Tank / Pipe
A. Manual Tank Gauging
B. Tank Tightness Testing
C. Inventory Control
D. Automatic Tank Gauging
E. Vapor Monitor
F. Groundwater Monitoring
G. SIR
H. Interstit. Dbl. Wall Monitoring
I. Interstit. Sec. Con. Monitoring
J. Auto Line Leak Detectors
K. Line Tightness Testing
L. Other
1. Please specify system used
14. Overfill Protected
15. Spill Protected

XIII – Oaths – I certify that the information concerning installation provided in this notification is true to the best of my knowledge.

Installers Name: ______

Title: ______

Company Name: ______

Signature: ______Date: ______

XIV – General Information

Notification for Underground Storage Tanks

A new Notification Form is requires for all UST systems whose status have been changed by tank removal, tank installation, tank system upgrading or change in service since the most recent notification form was submitted. The notification form must be submitted within 30 days after completion of the status change for the facility.

Who must notify?

Unless exempted in the regulation, All Owners or Operators of underground tanks that store regulated substances must register their tanks with Division of Oil and Public Safety.

What tanks are included?

UST is defined as any one or combination of tanks that:

(1)Is used to contain an accumulation of “regulated substances”

(2)Whose volume (including underground piping) is 10% or more beneath the ground

What tanks are excluded?

Tanks excluded from notification are:

(1)Farm or residential tanks of 1100 gallons or less capacity used for storing motor fuel for noncommercial purposes

(2)Tanks used for storing heating oil for consumptive use on the premises where stores

(3)Septic tanks

(4)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 intrastate pipeline facility regulated under state laws.

(5)Surface impoundments, pits, ponds or lagoons

(6)Storm water or waste water collection systems

(7)Flow-through process tanks

(8)Liquid traps or associated gathering lines directly related to oil or gas production and gathering operations

(9)Storage tanks situated in an underground area (such as a basement, cellar, mine working, drift, shaft or tunnel) if the storage tank is situated upon or above the floor surface

What Substances are covered?

Any substance defined as hazardous 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. It also includes petroleum, e.g., 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).