"Application Form for State Lead Program - Noncorrective Action for Ust Permanent Closure" - Arizona

Application Form for State Lead Program - Noncorrective Action for Ust Permanent Closure is a legal document that was released by the Arizona Department of Environmental Quality - a government authority operating within Arizona.

Form Details:

  • Released on September 24, 2018;
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ADEQ received stamp:
APPLICATION FOR STATE LEAD PROGRAM
UNDERGROUND STORAGE TANK (UST)
NONCORRECTIVE ACTION (A.R.S. § 49-1017.02)
FOR UST PERMANENT CLOSURE
Electronic Submittal:
ADEQ encourages you to submit this form electronically. Submittal of a complete and accurate
application form may allow for more timely review of your submittal.
*NOTE: this application cannot be processed unless ADEQ receives a completed Access Agreement with the signature of
the property owner. It is the Applicant’s responsibility to submit this form.
For instructions on how to submit electronic files, see Appendix A.
For Mail or hand deliver submittal:
ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY
Attention: UST State Lead Program
1110 W Washington St, Mail Code 4415B-3
Phoenix, AZ 85007
Eligibility is limited to UST owners, operators and property owners. Funding is not available for USTs owned by the state
of Arizona, the federal government or those located in Indian Country.
I,
am the applicant requesting ADEQ to conduct a UST
(Print Name)
permanent closure under 49-1017.02 and state that the information submitted by me in this application is true and
correct to the best of my knowledge.
Please complete the following:
How did you find out about this program?
Why are you permanently closing your UST(s)?
Are all USTs at the site being removed? ☐ Yes ☐ No
If “No”, are the USTs being removed in the same tank pit as those you intend to keep in use?
☐ Yes ☐ No
NOTE: Requested removal of one tank in a tank pit containing more than one tank will not be approved.
Is this facility going to continue storage of petroleum products? ☐ Yes
☐ No
If “Yes” are USTs being replaced by new UST system?
☐ Yes
☐ No
If “Yes” are USTs being replaced by an above-ground tank system (AST)? ☐ Yes ☐ No
Are there any site specific details that may impact the requested actions? _____________________________________
Examples: Canopy removal will be required due to location of UST system components.
Tanks are secured to a concrete pad (dead man).
Revised September 24, 2018
ADEQ received stamp:
APPLICATION FOR STATE LEAD PROGRAM
UNDERGROUND STORAGE TANK (UST)
NONCORRECTIVE ACTION (A.R.S. § 49-1017.02)
FOR UST PERMANENT CLOSURE
Electronic Submittal:
ADEQ encourages you to submit this form electronically. Submittal of a complete and accurate
application form may allow for more timely review of your submittal.
*NOTE: this application cannot be processed unless ADEQ receives a completed Access Agreement with the signature of
the property owner. It is the Applicant’s responsibility to submit this form.
For instructions on how to submit electronic files, see Appendix A.
For Mail or hand deliver submittal:
ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY
Attention: UST State Lead Program
1110 W Washington St, Mail Code 4415B-3
Phoenix, AZ 85007
Eligibility is limited to UST owners, operators and property owners. Funding is not available for USTs owned by the state
of Arizona, the federal government or those located in Indian Country.
I,
am the applicant requesting ADEQ to conduct a UST
(Print Name)
permanent closure under 49-1017.02 and state that the information submitted by me in this application is true and
correct to the best of my knowledge.
Please complete the following:
How did you find out about this program?
Why are you permanently closing your UST(s)?
Are all USTs at the site being removed? ☐ Yes ☐ No
If “No”, are the USTs being removed in the same tank pit as those you intend to keep in use?
☐ Yes ☐ No
NOTE: Requested removal of one tank in a tank pit containing more than one tank will not be approved.
Is this facility going to continue storage of petroleum products? ☐ Yes
☐ No
If “Yes” are USTs being replaced by new UST system?
☐ Yes
☐ No
If “Yes” are USTs being replaced by an above-ground tank system (AST)? ☐ Yes ☐ No
Are there any site specific details that may impact the requested actions? _____________________________________
Examples: Canopy removal will be required due to location of UST system components.
Tanks are secured to a concrete pad (dead man).
Revised September 24, 2018
ADEQ STATE LEAD PROGRAM – UST NONCORRECTIVE ACTION APPLICATION
Applicant Information:
Check all that apply to Applicant: ☐ UST Owner
☐ UST Operator
☐ Property Owner
Note: If Applicant is not the property owner, the applicant will be required to have the property owner complete the
attached site access agreement.
I am applying as: ☐ An Individual
☐ Company or Corporation ☐ Other (describe: ________________________)
If Applicant is an individual – Provide Full Legal Name: _____________________________________________________
If Applicant is not an individual - please provide the name of the Company and identify the Authorized Individual who has
(Note:
Provide documentation demonstrating that the Authorized Individual is a
the authority to represent the Company
bona fide employee of the Company or their legal representative. The Company name must match the information provided
on the Arizona Corporation Commission (ACC) website.):
Name of Applicant (Company Name): ____________________________________________________________
Name of Authorized Individual: _____________________
Address: _______________________________________________________________________
City: __________________________
State: __________
Zip Code: _________
Home Phone: ______________ Work Phone: ________________
Cell Phone: _________________
Fax: _______________________
Email: ________________________________________
This application cannot be processed unless ADEQ receives a completed Access Agreement with the signature of
the property owner. It is the Applicant’s responsibility to submit this form.
Property Owner Name: _________________________________________________________
If Property Owner is a business, identify contact person: ______________________________________________
Phone Number: _________________
Email: ___________________________________
Facility Information:
ADEQ assigned Facility ID Number: 0-0_______________
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: _____________________
State: __________
Zip Code: _________
Facility Contact Person
☐ Check if same as applicant, if not - complete information below:
Name: ________________________________________________________________________
Contact Phone Number: ________________
Email: ___________________________________
Owner and Operator Information:
Owner Name (if different from Applicant identified above): __________________________________
Address: ___________________________________________________________________________
City: _____________________
State: __________
Zip Code: _________
Operator Name (if different from Applicant identified above): _______________________________
Address: ___________________________________________________________________________
City: _____________________
State: __________
Zip Code: _________
☐ Unknown
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ADEQ STATE LEAD PROGRAM – UST NONCORRECTIVE ACTION APPLICATION
Financial Responsibility (FR) Requirements:
You paid for UST insurance. Don’t waste it!
As the tank owner and/or operator YOU are responsible for cleaning up contamination associated with your UST system.
We want you to be aware that your insurance policy may require you to provide them PRIOR notice of certain tank-related
activities.
For most UST owners and operators in Arizona, your financial assurance mechanism is UST insurance. To preserve your
rights to make a claim if contamination is found, you must comply with all the conditions in your policy. For example: you
may be required to notify your insurance company prior to UST removal or there may be strict time limits on when you
must notify them if contamination is discovered. Don’t take the risk that you will have to pay for clean-up because you did
not know your policy requirements.
If you rely upon UST insurance to demonstrate compliance with financial responsibility requirements, please provide the
following:
___________________________________
__________________________________
Insurance Provider Company Name
Policy Number
___________________________________
__________________________________
Insurance Provider Contact Name
Provider Contact Phone Number
Financial Resources of State Lead Applicant:
I understand that information about my financial resources is a factor that may be considered in determining the priority
of my request.
☐ I am not requesting a financial need evaluation.
☐ I am requesting a financial need evaluation.
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ADEQ STATE LEAD PROGRAM – UST NONCORRECTIVE ACTION APPLICATION
UST Information:
Attach a site plan showing the location of the USTs.
Are UST(s) currently in use (operating)? ☐ Yes ☐ No (If “No” provide date of last use__________________)
Number of tanks for which removal is being requested: ___________
Complete the following for USTs that will be removed:
Tank
Size
Installation
Construction
Material
Product Stored
No.
(gallons)
Date
(throughout operation)
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐Steel
☐UL Premium Gasoline
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐Steel
☐UL Premium Gasoline
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐Steel
☐UL Premium Gasoline
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
Piping Material: ☐Fiberglass Reinforced Plastic ☐Steel
☐Flexible
☐Unknown
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ADEQ STATE LEAD PROGRAM – UST NONCORRECTIVE ACTION APPLICATION
Additional UST Information (attach additional sheets if needed)
Tank
Size
Installation
Construction
Material
Product Stored
No.
(gallons)
Date
(throughout operation)
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐UL Premium Gasoline
☐Steel
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐UL Premium Gasoline
☐Steel
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
☐Single Walled
☐Fiberglass Reinforced Plastic
☐Unleaded (UL) Gasoline
☐UL Mid-grade Gasoline
☐Double Walled
☐UL Premium Gasoline
☐Steel
☐Leaded Gasoline
☐Internal Lining
☐Composite
☐E-85
☐Diesel
☐Unknown
☐Unknown
☐Biodiesel (B_____)
☐Used/Waste Oil
☐New Oil
☐Aviation Fuel
☐Jet Fuel (specify________)
☐Unknown
Piping Material: ☐Fiberglass Reinforced Plastic ☐Steel
☐Flexible
☐Unknown
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