Attachment_IV_-_DNR_Form_542-1392.pdf

07/2012 cmz DNR Form 542-1308

Iowa DNR – UST Section Notification of Tank Closure or Change-in-Service

Complete all sections and submit to the Iowa DNR at least 30 days before starting closure activities.

UST FACILITY

Name: Registration No:

Address: LUST No:

City: ZIP: Phone:

OWNER

Name: Phone:

Company:

Address:

City: State: ZIP:

TANK AND PIPING CLOSURE

Tank Closure Procedure: Month/Day/Year of Proposed Closing:

Removal of Tank(s) Piping Closure Only? Yes No

Closing Tank in Place by Filling with Inert Material Will Piping Be Removed? Yes No

Change-in-Service to Unregulated Use Will this tank/piping be replaced by a new underground storage tank/piping? Yes No

TANK INFORMATION

TANK # PERMANENT TAG NO CAPACITY CONTENTS DATE INSTALLED SINGLE OR DOUBLE WALL

SW / DW

SW / DW

SW / DW

SW / DW

SW / DW

SW / DW

REMOVER

Licensed Remover: License No:

Company:

Address: Phone:

EXCAVATOR

Name: Company:

CERTIFIED GROUNDWATER PROFESSIONAL (CGP)

Name: Company:

Signed Dated this day of , 20 (UST System Owner)

Signed Dated this day of , 20 (Remover)

Iowa Department of Natural Resources Underground Storage Tank Section

502 East 9th Street Des Moines, IA 50319-0034

Complete all sections of the notification form.

Provide site registration number assigned by DNR when the site was first registered.

This is not the tank tag number.

Indicate anticipated date of closure. 24 hour notice is also required to be given to local DNR field office.

Mark the tank closure procedure you will be following. Confirmation from the UST Section will follow. All three closure procedures require soil and groundwater sampling.

When closing a tank in place, analytical results must be submitted and approved by the DNR prior to filling the tank with inert material.

If approved groundwater or vapor monitoring has been used for leak detection, it may be possible to use the monitoring results from the 90 days prior to closure instead of soil and groundwater sampling at the time of closure. Contact the department if you feel your site qualifies for prior approval.

The form should be signed and dated by the tank owner or authorized agent and licensed remover and submitted to the DNR by the licensed remover.

Go to:

http://www.iowadnr.gov/InsideDNR/RegulatoryLand/UndergroundStorageTanks/Licens edUSTProfessionals.aspx to download appropriate documents.

Mail To:

Iowa Department of Natural Resources Underground Storage Tank Section 502 East 9th Street Des Moines, IA 50319-0034

This form must be mailed at least 30 days before closure activities commence.

http://www.iowadnr.gov/InsideDNR/RegulatoryLand/UndergroundStorageTanks/LicensedUSTProfessionals.aspx http://www.iowadnr.gov/InsideDNR/RegulatoryLand/UndergroundStorageTanks/LicensedUSTProfessionals.aspx