Form UST-SURV-01 "Notification of Intent to Perform a Closure or Change-In-Service to an Underground Storage Tank System" - Louisiana

What Is Form UST-SURV-01?

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

Form Details:

  • Released on August 1, 2009;
  • The latest edition provided by the Louisiana Department of Environmental Quality;
  • 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 fillable version of Form UST-SURV-01 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Environmental Quality.

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Download Form UST-SURV-01 "Notification of Intent to Perform a Closure or Change-In-Service to an Underground Storage Tank System" - Louisiana

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STATE OF LOUISIANA
NOTIFICATION OF INTENT TO PERFORM A CLOSURE OR CHANGE-IN-SERVICE
TO AN UNDERGROUND STORAGE TANK SYSTEM
Please complete and return thirty (30) days prior to permanent UST system closure or change-in-service.
LDEQ- UNDERGROUND STORAGE TANKS DIVISION
Return:
DEQ Facility Number
Appropriate Regional Office
See attached mailing list or USTD
DEQ AI Number
Questions: (225) 219-3181
Submittal info @ www.deq.louisiana.gov
I. OWNERSHIP OF TANKS
II. LOCATION OF TANKS
IF OWNER'S ADDRESS CHANGED, PLEASE CHECK
IF SAME AS SECTION I. PLEASE CHECK
OWNER NAME (CORPORATION/INDIVIDUAL, ETC.)
FACILITY NAME OR COMPANY SITE IDENTIFIER
MAILING ADDRESS
STREET ADDRESS (P. O. BOX NOT ACCEPTABLE)
CITY
STATE
ZIP
CITY
STATE
ZIP
PARISH/COUNTY
PARISH
(
)
(
)
TELEPHONE (INCLUDE AREA CODE)
TELEPHONE (INCLUDE AREA CODE)
NAME OF CONTACT
CONTACT PERSON AT THIS LOCATION
III. TANK INFORMATION
DATE SCHEDULED FOR CLOSURE/REMOVAL OR CHANGE-IN-SERVICE
SIZE OF TANK
SIZE OF TANK
DEQ ASSIGNED
PRODUCT LAST
DEQ ASSIGNED
PRODUCT LAST
(GALLONS)
TANK NUMBERS
(GALLONS)
STORED IN TANK
TANK NUMBERS
STORED IN TANK
ATTACH CONTINUATION SHEETS IF NECESSARY
IV. TANK CLOSURE INFORMATION
A. If the tank(s) are to be closed in place, indicate cleaning method and the type of fill material to be used:
B. Name of UST Certified Worker
Certificate No.
C. Name of Contracting Company
D. Name of laboratory to conduct sample analysis
FORMS THAT INCLUDE "TO BE DETERMINED" OR "UNKNOWN" AS A RESPONSE WILL BE REJECTED
V. CERTIFICATION
I certify that the above information is correct to the best of my knowledge and that the appropriate UST Regional Office will be contacted seven days
prior to performing the UST system closure or change-in-service. I agree if closure or change-in-service of the UST system does not begin within 90
days after DEQ's approval, that this form becomes invalid. I also agree to submit the following information within 60 days after closure/change-in-
service of the UST system:
(1) the 'UST Closure/Assessment Form' (UST-SURV-02);
(2) two copies of a site drawing to include the information required by the "Underground Storage Tank Closure/Change-in-
Service Assessment Guidelines";
(3) two copies of analytical results with chain-of-custody documents; and
(4) two copies of all manifests, bills of lading or receipts for the disposition of tank(s), tank contents, soil and waters.
PRINT OR TYPE OWNER'S NAME
OWNER'S SIGNATURE
DATE
FORMS THAT DO NOT INCLUDE THE OWNER'S SIGNATURE WILL BE REJECTED
LDEQ RESPONSE - DO NOT WRITE BELOW THIS LINE
DEQ
AI
No.__________________
Approved for the indicated activity.
Rejected for the following reason:
DEQ records indicate that the contractor you have selected is not a UST worker certified by DEQ for closure. You
must select, from the enclosed list, a contractor that is a certified UST worker.
DEQ records indicate that the UST system has not been registered. You must complete the attached registration form
and return it to this office IMMEDIATELY.
The noted highlighted section(s) of this form must be completed in order for LDEQ to process.
This form has not been signed by the owner. Please resubmit with the required signature.
Signature of LDEQ
Representative
Telephone No. -
Date
/
/
UST-SURV-01
Revised 08/09
* * * * INCOMPLETE FORMS MAY BE REJECTED * * * *
Print Form
STATE OF LOUISIANA
NOTIFICATION OF INTENT TO PERFORM A CLOSURE OR CHANGE-IN-SERVICE
TO AN UNDERGROUND STORAGE TANK SYSTEM
Please complete and return thirty (30) days prior to permanent UST system closure or change-in-service.
LDEQ- UNDERGROUND STORAGE TANKS DIVISION
Return:
DEQ Facility Number
Appropriate Regional Office
See attached mailing list or USTD
DEQ AI Number
Questions: (225) 219-3181
Submittal info @ www.deq.louisiana.gov
I. OWNERSHIP OF TANKS
II. LOCATION OF TANKS
IF OWNER'S ADDRESS CHANGED, PLEASE CHECK
IF SAME AS SECTION I. PLEASE CHECK
OWNER NAME (CORPORATION/INDIVIDUAL, ETC.)
FACILITY NAME OR COMPANY SITE IDENTIFIER
MAILING ADDRESS
STREET ADDRESS (P. O. BOX NOT ACCEPTABLE)
CITY
STATE
ZIP
CITY
STATE
ZIP
PARISH/COUNTY
PARISH
(
)
(
)
TELEPHONE (INCLUDE AREA CODE)
TELEPHONE (INCLUDE AREA CODE)
NAME OF CONTACT
CONTACT PERSON AT THIS LOCATION
III. TANK INFORMATION
DATE SCHEDULED FOR CLOSURE/REMOVAL OR CHANGE-IN-SERVICE
SIZE OF TANK
SIZE OF TANK
DEQ ASSIGNED
PRODUCT LAST
DEQ ASSIGNED
PRODUCT LAST
(GALLONS)
TANK NUMBERS
(GALLONS)
STORED IN TANK
TANK NUMBERS
STORED IN TANK
ATTACH CONTINUATION SHEETS IF NECESSARY
IV. TANK CLOSURE INFORMATION
A. If the tank(s) are to be closed in place, indicate cleaning method and the type of fill material to be used:
B. Name of UST Certified Worker
Certificate No.
C. Name of Contracting Company
D. Name of laboratory to conduct sample analysis
FORMS THAT INCLUDE "TO BE DETERMINED" OR "UNKNOWN" AS A RESPONSE WILL BE REJECTED
V. CERTIFICATION
I certify that the above information is correct to the best of my knowledge and that the appropriate UST Regional Office will be contacted seven days
prior to performing the UST system closure or change-in-service. I agree if closure or change-in-service of the UST system does not begin within 90
days after DEQ's approval, that this form becomes invalid. I also agree to submit the following information within 60 days after closure/change-in-
service of the UST system:
(1) the 'UST Closure/Assessment Form' (UST-SURV-02);
(2) two copies of a site drawing to include the information required by the "Underground Storage Tank Closure/Change-in-
Service Assessment Guidelines";
(3) two copies of analytical results with chain-of-custody documents; and
(4) two copies of all manifests, bills of lading or receipts for the disposition of tank(s), tank contents, soil and waters.
PRINT OR TYPE OWNER'S NAME
OWNER'S SIGNATURE
DATE
FORMS THAT DO NOT INCLUDE THE OWNER'S SIGNATURE WILL BE REJECTED
LDEQ RESPONSE - DO NOT WRITE BELOW THIS LINE
DEQ
AI
No.__________________
Approved for the indicated activity.
Rejected for the following reason:
DEQ records indicate that the contractor you have selected is not a UST worker certified by DEQ for closure. You
must select, from the enclosed list, a contractor that is a certified UST worker.
DEQ records indicate that the UST system has not been registered. You must complete the attached registration form
and return it to this office IMMEDIATELY.
The noted highlighted section(s) of this form must be completed in order for LDEQ to process.
This form has not been signed by the owner. Please resubmit with the required signature.
Signature of LDEQ
Representative
Telephone No. -
Date
/
/
UST-SURV-01
Revised 08/09
* * * * INCOMPLETE FORMS MAY BE REJECTED * * * *
NOTIFICATION OF INTENT TO PERFORM A CLOSURE
OR CHANGE-IN-SERVICE
TO AN UNDERGROUND STORAGE TANK SYSTEM
NOTICES WILL ONLY BE ACCEPTED ON THIS FORM.
YOUR UNDERGROUND STORAGE TANK MUST BE REGISTERED
PRIOR TO SUBMITTAL OF THIS FORM.
INSTRUCTIONS
THIRTY DAYS prior to permanent closure or change-in-service of a UST, all information
required on this form must be completed. Forms that are incomplete may be rejected.
After completion, the UST owner is to forward the original, signed form to:
LDEQ-UNDERGROUND STORAGE TANKS DIVISION
Appropriate Regional Office
See attached mailing list or USTD
Submittal info@www.deq.louisiana.gov
The Underground Storage Tanks Division will distribute copies of the form as follows:
1.
Original – UST Division Main Office
2.
Copy - DEQ Regional Office File
3.
Copy - UST Owner (After DEQ Processing)
PROCEDURES TO BE FOLLOWED
The procedures which must be followed when performing a UST closure or change-
in-service are provided in the "Underground Storage Tank Closure/Change-in-
Service Guidance Document". To obtain a copy of this document, call the
Underground Storage Tanks Division at (225) 219-3181, write to the address noted
above, or visit our website at www.deq.louisiana.gov.
NOTICE
Chapter 13 of the UST Regulations requires that owners of USTs ensure that the
contractor chosen to perform the UST closure/change-in-service employs an
individual who holds a current Louisiana DEQ certificate for closure. The certified
person must be present at the site and excercising responsible supervisory control
during the closure/change-in-service process. A list of contractors who employ DEQ
certified workers can be obtained from the Underground Storage Tanks Division, at
(225) 219-3181, or on the web at www.deq.louisiana.gov.
Notification Of Intent To Perform A Closure Or Change-In-Service
To An Underground Storage Tank System
Please direct all correspondence regarding UST Closures or Change-in-Service to
the appropriate regional office:
Parishes Served
Acadiana Regional Office
111 New Center Drive
Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, St.
Lafayette, LA 70508
Mary, Vermilion
phone: (337) 262-5584
fax: (337) 262-5593
Capital Regional Office
Parishes Served
ATTN: UST Division - Surveillance Process
P.O. Box 4313
Ascension, Assumption, East Baton Rouge, East Feliciana, St.
Baton Rouge, LA 70821-4313
Martin, Tangipahoa, West Baton Rouge, West Feliciana
phone: (225) 219-3181
fax: (225) 219-3474
Parishes Served
Northeast Regional Office
1823 Hwy 546
Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison,
West Monroe, LA 71292
Morehouse, Ouchita, Richland, Tensas, Union, West Carroll
phone: (318) 362-5439
fax: (318) 362-5448
Kisatchie Central Office
(Located in the Northeast Regional Office Service Area)
402 Rainbow Drive, Bldg. 402
Avoyelles, Catahoula, Concordia, Grant, La Salle, Rapides, Winn
Pineville, LA 71360
phone: (318) 487-5656
fax: (318) 487-5927
Northwest Regional Office
Parishes Served
1525 Fairfield Ave, Room 520
Bienville, Bossier, Caddo, Claiborne, De Soto, Natchitoches, Red
Shreveport, LA 71101-4388
phone: (318) 676-7476
River, Sabine, Webster
fax: (318) 676-7573
Southeast Regional Office
Parishes Served
New Orleans Office
201 Evans Road, Building 4, Suite 420
Jefferson, Lafourche, Orleans, Plaquemines, St. Bernard,
New Orleans, LA 70123-5230
Washington
phone: (504) 736-7701
fax: (504) 736-7702
Bayou Lafourche Office
(Located in the Southeast Regional Office Service Area)
Jefferson, Lafourche, Orleans, Plaquemines, St. Bernard,
110 Barataria St.
Washington
Lockport, LA 70374
phone: (985) 532-6206
fax: (985) 532-9945
Parishes Served
Southwest Regional Office
1301 Gadwall Street
Lake Charles, LA 70615
Allen, Beauregard, Calcasieu, Cameron, Jefferson Davis, Vernon
phone: (337) 491-2667
fax: (337) 491-2682
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