UNDERGROUND STORAGE TANK CLOSURE REPORT FORM
Submit this Report & Attachments within 45 days of scheduled permanent closure
Failure to submit the Tank Closure Report within 45 days is a violation of rule 165:25-1-55 subject to a $250 penalty.CONFIRMATION # BF# FACILITY I.D. #
OWNER’S NAMELOCATION NAME
MAILING ADDRESSLOCATION ADDRESS (PHYSICAL LOCATION)
CITYSTATEZIPCITYSTATEZIP
COUNTYAREA CODE/TELEPHONECOUNTYAREA CODE/TELEPHONE
DATE WORK COMPLETEDDATE TANKS LAST USEDNEW INSTALLATION OR NUMBER/SIZE OF ACTIVE TANKS
____
NUMBER/SIZE OF TANKS REMOVEDCONDITION OF REMOVED TANKS. ANY VISIBLE HOLES?
DESCRIBE DISPOSAL /DISPOSITION OF REMOVED TANKS AND LINES (Tanks cannot be reused unless recertified by manufacturer. Cannot be used as culverts, etc.) ______
Were samples collected at each elbow, connection Was excavated soil removed from site?
in the piping run, or at least every 20 feet______▀ Was soil manifested to a permitted landfill? ______
▀ Were samples collected under each tank and Name of Landfill ______
down gradient wall? ______▀ Was backfill returned to the excavation? ______
NUMBER/SIZE OF TANKS CLOSED-IN-PLACE -- INDICATE TYPE OF INERT MATERIAL USED: ______
Assess the site for potential contamination by testing soil and/or groundwater; OCC approved by: ______
Were field-screening instruments used? Type & Model Number:
Date instrument last calibrated: Calibrated to (type gas):
NOTE: If soil or groundwater samples are used for site assessment, person taking samples must be supervised by a Licensed Environmental Consultant.NAME OF LICENSED ENVIRONMENTAL CONSULTANTCOMPANY
ADDRESSCITYSTATEZIP
I certify the samples were taken at locations where contamination would most likely have occurred:
CONSULTANT SIGNATURE/LICENSE #DATE SIGNEDAREA CODE/TELEPHONE
Attach a site sketch that includes:
(a)North arrow (b) tank pit location (c) proximity of tank pit to roads, buildings or other landmarks measured in feet; (d) piping layout and pump island location(s) (e) soil sample locations, sample depths, and sample identification.
Also attach: (a) scheduling letter (b) table of lab results & reports (c) waste manifest(s) (d) certificate of destruction for tank(s)
(e) photographic documentation (f) description of site activities and observations (g) OCC registration form.
PLEASE NOTE THAT INCOMPLETE OR MISSING INFORMATION WILL CAUSE REPORT TO BE RETURNED
TANK REMOVAL ACTIVITIES MUST BE SUPERVISED AT ALL TIMES BY LICENSED UST REMOVER
NAME OF LICENSED REMOVERCOMPANY
ADDRESSCITYSTATEZIP
I certify that I personally supervised all (beginning with breakout of concrete) onsite tank removal activities:
______
UST REMOVER SIGNATURE/LICENSE #DATE SIGNEDAREA CODE/TELEPHONE
OKLAHOMA CORPORATION COMMISSION, PETROLEUM STORAGE TANK DIVISION
P. O. BOX 52000, OKLAHOMA CITY, OK 73152-2000
(405) 521-4683(Revised 07-2006)