Form MO780-2120 "Closure Report for Petroleum Releases at Underground Storage Tank Sites" - Missouri

What Is Form MO780-2120?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO780-2120 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-2120 "Closure Report for Petroleum Releases at Underground Storage Tank Sites" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL REMEDIATION PROGRAM
CLOSURE REPORT FOR PETROLEUM RELEASES
AT UNDERGROUND STORAGE TANK SITES
Return completed form to:
Missouri Department of Natural Resources
Environmental Remediation Program/Tanks Section
PO Box 176
Jefferson City, MO 65102
SITE NAME
SITE NUMBER
RELEASE NUMBER
SITE ADDRESS
CITY
STATE
ZIP CODE
PREPARED BY
REVIEWED BY
SUBMITTAL DATE
FACILITY INFORMATION
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
E-MAIL ADDRESS
DATE OF PROJECT INITITATION
DATE OF PROJECT COMPLETITION
UNDERGROUND STORAGE TANK (UST) OWNER INFORMATION
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
CONTACT PERSON
E-MAIL ADDRESS
PARTY PERFORMING CLOSURES
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
CONTACT PERSON
E-MAIL ADDRESS
CERTIFICATION OF PROPER CLOSURE
I certify that the information in this report is true and complete.
SIGNATURE OF PARTY PERFORMING CLOSURE
DATE
SIGNATURE OF OWNER/OPERATOR
DATE
MO 780-2120 (12-20)
Page 1
MISSOURI DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL REMEDIATION PROGRAM
CLOSURE REPORT FOR PETROLEUM RELEASES
AT UNDERGROUND STORAGE TANK SITES
Return completed form to:
Missouri Department of Natural Resources
Environmental Remediation Program/Tanks Section
PO Box 176
Jefferson City, MO 65102
SITE NAME
SITE NUMBER
RELEASE NUMBER
SITE ADDRESS
CITY
STATE
ZIP CODE
PREPARED BY
REVIEWED BY
SUBMITTAL DATE
FACILITY INFORMATION
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
E-MAIL ADDRESS
DATE OF PROJECT INITITATION
DATE OF PROJECT COMPLETITION
UNDERGROUND STORAGE TANK (UST) OWNER INFORMATION
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
CONTACT PERSON
E-MAIL ADDRESS
PARTY PERFORMING CLOSURES
NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER WITH AREA CODE
CONTACT PERSON
E-MAIL ADDRESS
CERTIFICATION OF PROPER CLOSURE
I certify that the information in this report is true and complete.
SIGNATURE OF PARTY PERFORMING CLOSURE
DATE
SIGNATURE OF OWNER/OPERATOR
DATE
MO 780-2120 (12-20)
Page 1
UNDERGROUND STORAGE TANK DISPOSAL INFORMATION
Fate of tank:
Recycle/Savage
Landfill
Unregulated (explain)
FINAL DESTINATION OF TANKS
ADDRESS OF FINAL DESTINATION
CITY
STATE
ZIP CODE
SOIL DISPOSAL INFORMATION
CUBIC YARDS OF SOIL EXCAVATED
CUBIC YARDS OF NON-CONTAMINATED SOIL RETURNED TO PIT
CUBIC YARDS OF CONTAMINATED SOIL DISPOSED OR RETURNED
DISPOSAL OF PETROLEUM-CONTAMINATED WATER
GALLONS OF WASTEWATER GENERATED
Check disposable method and explain:
Hazardous waste disposal firm:
On-site discharge under general permit limits:
Discharge to wastewater treatment plant:
DISPOSAL OF SLUDGE/RINSATE
GALLONS OF SLUDGE/RINSATE DISPOSED
HAZARDOUS WASTE DISPOSAL FIRM
HAZARDOUS WASTE DISPOSAL FIRM ADDRESS
CITY
STATE
ZIP CODE
UNDERGROUND STORAGE TANKS CLOSED
Underground
Storage Tank
Tank
Capacity
Year
Date removed
Construction
Number
(gallons)
Installed
from service (use)
Material
Product Stored
Method of Closure*
* R=Removal, I=In-place
USER REGISTRATION
Are Underground Storage Tanks registered?
Yes
No
MANDATORY ATTACHMENTS
1. Attach a map or multiple maps of the site which includes:
2. Attach color photographs of the following:
a) Size and contents of all Underground Storage Tanks.
a) All sides of the removed Underground Storage Tanks.
b) Locations and lengths of all fuel lines.
b) Each wall and floor of the excavation pit, if USTs are
c) Locations of all pump islands.
removed.
d) Location of the excavation pit boundaries.
c) All sealed vent or pipe lines (if applicable).
e) Locations of all required samples using the specified
d) The sealed Underground Storage Tanks, if closed in-
labeling format.
place.
f) Location of all above ground tanks and associated piping,
e) The site before the initiation of the closure and after the
plus the size and contents of each.
completion of the closure.
g) Depth to the bottom of each tank and depth of all
3. Attach appropriate documentation of soil disposal or
excavations.
treatment.
h) Direction and degree of slope on the site.
4. Attach copy of "Virgin Product Disposal Form" or "Special
i) Scale of the sketch in feet.
Waste Form" if applicable.
j) Properties immediately adjacent to the site.
5. Attach bills of sale/certificate of disposal.
MO 780-2120 (12-20)
Page 2
RESULTS OF SOIL ANALYSIS
SITE NUMBER
SUBMITTAL DATE
PREPARED BY
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
On-site
Select one:
On-Site
Off-Site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Off-site
Arithmetic
Arithmetic
MW / SB No.
Average
Maximum
Average
Maximum
Sampling Date
Only for review purposes,
not necessarily used as
Sample Depth (feet)
representative concentrations.
Organics (all concentrations must be in mg/kg)
Benzene
Toluene
Ethyl benzene
Xylenes (mixed)
Ethylene Dibromide (EDB)
Ethylene Dichloride (EDC)
Methyl-tert-butyl-ether (MTBE)
Acenaphthene
Anthracene
Benzo(a)anthracene
Benzo(a)pyrene
Benzo(b)fluoranthene
Benzo(k)fluoranthene
Chrysene
Dibenzo(a,h)anthracene
Fluoranthene
Fluorene
Naphthalene
Pyrene
TPH-GRO
TPH-DRO
TPH-ORO
Tertiary-amyl-methyl-ether (TAME)
MO 780-2120 (12-20)
Page 3
RESULTS OF SOIL ANALYSIS (CONTINUED)
Tertiary-butyl- alcohol (TBA)
Ethyl-tert-butyl-ether (ETBE)
Di-isopropyl ether (DIPE)
Ethanol
Methanol
Metals (all concentrations must be in mg/kg)
Arsenic
Barium
Cadmium
Chromium (III)
Chromium (VI)
Lead
Selenium
Note: Non-detects must be entered as <detection limit (for example: <0.005).
Maximum is the greater of (i) the detected values, and (ii) one-half of the detection limit.
Mandatory Attachments: 1. Site map showing location(s) of surficial soil samples.
2. Any laboratory analytical datasheets and chain of custody forms not previously submitted to the department.
N/A: Not applicable
MO 780-2120 (12-20)
Page 4
RESULTS OF GROUNDWATER ANALYSIS
SITE NUMBER
SUBMITTAL DATE
PREPARED BY
Arithmetic
Maximum
Average
MW / SB Number
Sampling Date
Only for review purposes,
not necessarily used as
Sample Depth (ft)
representative concentrations.
Organics (all concentrations must be in mg/L)
Benzene
Toluene
Ethyl benzene
Xylenes (mixed)
Ethylene Dibromide (EDB)
Ethylene Dichloride (EDC)
Methyl-tert-butyl-ether(MTBE)
Acenaphthene
Anthracene
Benzo(a)anthracene
Benzo(a)pyrene
Benzo(b)fluoranthene
Benzo(k)fluoranthene
Chrysene
Dibenzo(a,h)anthracene
Fluoranthene
Fluorene
Naphthalene
Pyrene
TPH-GRO
TPH-DRO
TPH-ORO
Tertiary-amyl-methyl-ether (TAME)
Tertiary-butyl- alcohol (TBA)
MO 780-2120 (12-20)
Page 5
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