Exhibit C - UST Closure Inspection Report.docx

BPM005267 Exhibit C

UST CLOSURE INSPECTION REPORT

ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY

1110 West Washington Street, Phoenix, Arizona 85007 ADEQ Help Line (In-State Only) 1-800-234-5677

Arrival Time

Departure Time

Number of days inspector will be needed on-site to observe the removal of USTs, dispenser sumps, and piping and observe all sampling

Facility Name

Facility Address

SYSTEM OWNER INFORMATION

UST Owner Name

Mailing Address

Owner Contact Name

Contact Title

Owner Contact Email

Contact Phone #

Owner’s On-Site Rep

Title / Company

On-site Rep Email

On-site Rep Phone

DECOMMISSIONING SERVICE PROVIDER INFORMATION

Service Provider Company

Service Provider Address

Service Provider Name

Email Address

Office Phone #

ENVIRONMENTAL COMPANY INFORMATION

Environmental Company

Company Address

Registered Professional

Office Phone #

Registered Professional Email

Primary Phone #

On-Site Rep Name / Title

On-Site Rep Email Address

Primary Phone #

Additional On-Site Personnel

AZDEQ REPRESENTATIVE INFORMATION

AZDEQ Rep

AZDEQ Rep Title

Email

Phone Number

Accompanied by

Title

FACILITY CONDITIONS

Condition of Surface (New, Degraded, Cracked, etc)

Significant Precipitation (Rain or Snow) Immediately Prior to or During Excavation Activities at the Facility

Facility Currently Occupied (Closed, Active, Razed, etc)

Type of Business (Auto Repair, Tire Shop, Office, etc)

OPEN SUSPECTED RELEASE/S ( ☐ No OPEN Suspected Releases in AZURITE)

Suspected Release #

Date Reported

Location Information

Suspected Release #

Date Reported

Location Information

OPEN CONFIRMED RELEASE/S ( ☐ No OPEN Confirmed Releases in AZURITE)

LUST #

Date Confirmed

Location Information

LUST #

Date Confirmed

Location Information

EVIDENCE OF RELEASE OBSERVED DURING CLOSURE ACTIVITIES

TANK INFORMATION (LIST COMPARTMENTS IN SEPARATE COLUMNS)

Tank ID #

Installation Date

Temporary Closure

Reason for being placed in Temporary Closure

Tank Manufacturer

Tank Model

Tank UL or Serial #

Tank Diameter

Tank Length

FOR USTs CLOSED IN PLACE: N/A ☐

Identify inert material(s) used to fill UST

UST REMOVAL INFORMATION

Tank ID #

excavation damage

Date of TRIPLE RINSE

Triple Rinse conducted by

If inerted, pounds of Dry Ice used per compartment (attach receipt)

GAS MONITOR Manufacturer / Model

Serial Number

Date of Last Calibration

If purged, LEL level (must be below 10% LEL)

If inerted, O2 level (must be below 7% O2)

Time removed from basin

COMMENTS regarding removal of USTs

OBSERVATIONS DURING VISUAL INSPECTION OF UST after placed on level ground and blocked/secured:

DISPOSAL OF USTs

Tank ID #

Disposal of Removed UST

ON END OF ALL USTs:

· ADEQ # DCxxxx.xxx

· Tank’s former contents such as UNLEADED 87; PREMIUM 91; DIESEL; . . .

· the date of removal

· Tank #

· inerted: % O2 --OR-- purged: % LEL

· NOT FOR REUSE

ON SIDE OF USTs undergoing Transfer of Ownership:

· NOT FOR STORAGE OF FOOD OR LIQUIDS for HUMANS or ANIMALS

USTs removed during these closure activities ARE NOT SUITABLE FOR STORAGE OF FOOD OR LIQUIDS for HUMANS or ANIMALS (API 1604) and are not to be re-used in this manner.

Final Disposal of USTs: Provide documentation regarding the disposal of the USTs by submitting a copy of the Certificate of Destruction or Bill of Sale for each UST removed during these closure activities to USTPlanReview@azdeq.gov.

Destination

Comments regarding the disposal of the USTs

SAMPLING WITHIN UST BASIN

Time soil sampling began

Time between UST removal and sampling

soil samples

Deepest samples were collected at x’ below grade

Number of soil samples collected beneath UST

Documented number of soil samples collected beneath the USTs

Evidence of Release?

(add comment below)

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

Additional soil samples were collected below the initial set of samples where Evidence of Release occurred (add comment below)

DISPENSER INFORMATION

Dispenser Manufacturer (if available)

Dispenser Model

UDC model

COMMENTS about dispensers

PIPING INFORMATION

Tank ID #

Piping Model (if available)

Piping Model (if available)

COMMENTS about piping

FOR PIPING CLOSED IN PLACE: N/A ☐

to ‘ BGS From ‘ BGS to ‘ BGS

‘ BGS

ppm

‘ BGS

‘ BGS

ppm

‘ BGS

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

GENERAL SAMPLING INFORMATION

Completed inspection. Debriefed service provider. Departed site at

Finalized report at office. Submitted report from office on /2022.

Inspector’s Printed Name

Inspector’s Signature

Date

Service Provider Printed Name

Service Provider Signature

Date

DC UST Closure Inspection Report, page 10

PHOTOS

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