PRINT
STATE OF LOUISIANA
UNDERGROUND STORAGE TANK CLOSURE/ASSESSMENT FORM – PLEASE TYPE
Please complete and return within sixty (60) days after UST system closure or change-in-service
Return to:
DEQ Agency Interest Number
LDEQ - UNDERGROUND STORAGE TANK & REMEDIATION DIVISION
Appropriate Regional Office See attached mailing list or
Questions:
DEQ Facility ID Number
USTRD Submittal information at www.deq.louisiana.gov
(225) 219-3443
I. OWNERSHIP OF TANKS
II. LOCATION OF TANKS
IF SAME AS SECTION I. PLEASE CHECK
IF OWNER'S ADDRESS CHANGED, PLEASE CHECK
FACILITY NAME OR COMPANY SITE IDENTIFIER
OWNER NAME (CORPORATION/INDIVIDUAL, ETC.)
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 PERSON
CONTACT PERSON AT THIS LOCATION
III. TANK INFORMATION (Attach Continuation Sheets If Necessary)
CHOOSE ONE PER TANK
TANK
HIGHEST LEL
DATE OF
PROPERLY
1 = Removed
OR OXYGEN
CLOSURE OR
DEQ ASSIGNED
PRODUCT LAST
SIZE OF TANKS
LABELED?
2 = Closed-in-Place
READING
CHANGE-IN-
TANK NUMBERS
STORED IN TANK
3
(GALLONS)
3 = Change-in-Service
1
SERVICE
LEL
Oxygen
4 = Removed & Replaced
2
Yes
4
No
1 - Indicate the non-regulated substance to be stored in the tank.
3 - Highest reading recorded just before tank removed from excavation.
2 - A registration form addressing the replacement tank must be completed.
4 - Lower Explosive Limit
V. TANK SLUDGES
IV. TANK
VI. TANK WATERS/WASHWATERS
A. Date cleaned:
A. Date disposed/recycled:
A. Date disposed/recycled:
B. Date disposed/recycled:
3
B. Volume removed (yd
):
B. Volume removed (gals):
C. Name of disposal/recycling site:
C. Name of disposal/recycling site:
C. Name of disposal/recycling site:
VII. CONTAMINATED SOIL
VIII. CONTAMINATED GROUNDWATER
A. Date removed:
D. Date disposed:
A. Date removed:
D. Date disposed:
3
B. Volume of soil removed (yd
):
B. Volume of groundwater removed (gals):
C. Name of disposal site:
C. Name of disposal/recycle site:
IX. CERTIFICATION
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my
inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.
PRINT OR TYPE OWNER'S NAME
OWNER'S SIGNATURE
DATE
PRINT OR TYPE NAME OF CERTIFIED WORKER
SIGNATURE OF CERTIFIED UST WORKER
CERTIFICATE NO.
DATE
FORMS THAT DO NOT INCLUDE THE OWNER'S AND UST WORKER'S SIGNATURES WILL BE REJECTED.
LDEQ RESPONSE - DO NOT WRITE BELOW THIS LINE
Closure Form Approved. UST system removed from database.
No confirmed release. No further action required at this time.
Confirmed release closed (SPLP, fractionation, excavation, or conveyance). No further action required at this time.
Confirmed release - referred for remediation review.
TEMPO Incident Number(s):
Closure Form Rejected. Additional information required:
Signature of LDEQ
Supervisor's
Telephone No. -
Date
/
/
Representative
Initials
UST-SURV-02
* * * * INCOMPLETE FORMS WILL BE REJECTED * * * *
Revised 6/14
PRINT
STATE OF LOUISIANA
UNDERGROUND STORAGE TANK CLOSURE/ASSESSMENT FORM – PLEASE TYPE
Please complete and return within sixty (60) days after UST system closure or change-in-service
Return to:
DEQ Agency Interest Number
LDEQ - UNDERGROUND STORAGE TANK & REMEDIATION DIVISION
Appropriate Regional Office See attached mailing list or
Questions:
DEQ Facility ID Number
USTRD Submittal information at www.deq.louisiana.gov
(225) 219-3443
I. OWNERSHIP OF TANKS
II. LOCATION OF TANKS
IF SAME AS SECTION I. PLEASE CHECK
IF OWNER'S ADDRESS CHANGED, PLEASE CHECK
FACILITY NAME OR COMPANY SITE IDENTIFIER
OWNER NAME (CORPORATION/INDIVIDUAL, ETC.)
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 PERSON
CONTACT PERSON AT THIS LOCATION
III. TANK INFORMATION (Attach Continuation Sheets If Necessary)
CHOOSE ONE PER TANK
TANK
HIGHEST LEL
DATE OF
PROPERLY
1 = Removed
OR OXYGEN
CLOSURE OR
DEQ ASSIGNED
PRODUCT LAST
SIZE OF TANKS
LABELED?
2 = Closed-in-Place
READING
CHANGE-IN-
TANK NUMBERS
STORED IN TANK
3
(GALLONS)
3 = Change-in-Service
1
SERVICE
LEL
Oxygen
4 = Removed & Replaced
2
Yes
4
No
1 - Indicate the non-regulated substance to be stored in the tank.
3 - Highest reading recorded just before tank removed from excavation.
2 - A registration form addressing the replacement tank must be completed.
4 - Lower Explosive Limit
V. TANK SLUDGES
IV. TANK
VI. TANK WATERS/WASHWATERS
A. Date cleaned:
A. Date disposed/recycled:
A. Date disposed/recycled:
B. Date disposed/recycled:
3
B. Volume removed (yd
):
B. Volume removed (gals):
C. Name of disposal/recycling site:
C. Name of disposal/recycling site:
C. Name of disposal/recycling site:
VII. CONTAMINATED SOIL
VIII. CONTAMINATED GROUNDWATER
A. Date removed:
D. Date disposed:
A. Date removed:
D. Date disposed:
3
B. Volume of soil removed (yd
):
B. Volume of groundwater removed (gals):
C. Name of disposal site:
C. Name of disposal/recycle site:
IX. CERTIFICATION
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my
inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.
PRINT OR TYPE OWNER'S NAME
OWNER'S SIGNATURE
DATE
PRINT OR TYPE NAME OF CERTIFIED WORKER
SIGNATURE OF CERTIFIED UST WORKER
CERTIFICATE NO.
DATE
FORMS THAT DO NOT INCLUDE THE OWNER'S AND UST WORKER'S SIGNATURES WILL BE REJECTED.
LDEQ RESPONSE - DO NOT WRITE BELOW THIS LINE
Closure Form Approved. UST system removed from database.
No confirmed release. No further action required at this time.
Confirmed release closed (SPLP, fractionation, excavation, or conveyance). No further action required at this time.
Confirmed release - referred for remediation review.
TEMPO Incident Number(s):
Closure Form Rejected. Additional information required:
Signature of LDEQ
Supervisor's
Telephone No. -
Date
/
/
Representative
Initials
UST-SURV-02
* * * * INCOMPLETE FORMS WILL BE REJECTED * * * *
Revised 6/14
UNDERGROUND STORAGE TANK CLOSURE/ASSESSMENT FORM
INSTRUCTIONS
Within SIXTY DAYS after completing a UST closure or change-in-service, this form, along with two copies of the following
must be provided to the Underground Storage Tank & Remediation Division:
1. Site drawing;
2. Analytical results with chain-of-custody documents; and
3. Copies of all manifests, bills of lading or receipts for the disposition of the tank(s), tank
contents, soil and waters.
All applicable information required on the form must be addressed
FORMS THAT ARE INCOMPLETE WILL BE REJECTED
After completion, the owner is to forward the completed form to:
LDEQ - UNDERGROUND STORAGE TANK & REMEDIATION DIVISION
Appropriate Regional Office
See attached mailing list or
USTRD Submittal information at www.deq.louisiana.gov
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 the current document call
the Underground Storage Tank & Remediation Division at (225) 219-3443, 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 exercising 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 Tank &
Remediation Division, at (225) 219-3443, or on the web at www.deq.louisiana.gov.
The Underground Storage Tank & Remediation Division will distribute copies of the completed form as follows:
1 . Original – LDEQ Main Office (EDMS)
2. Copy – UST Owner (after DEQ Regional Office processing)
3. Copy – USTRD HQ for TEMPO Entry
Underground Storage Tank System Installations, Repairs, and Closures
Please direct all correspondence regarding UST System Installations, Repairs, and Closures to
the appropriate regional office:
Acadiana Regional Office
Parishes Served
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: USTR Division - Surveillance Process
Ascension, Assumption, East Baton Rouge, East Feliciana, Iberville,
P.O. Box 4312
Livingston, Pointe Coupee, St. Helena, St. James, St. Martin,
Baton Rouge, LA 70821-4312
Tangipahoa, West Baton Rouge, West Feliciana
phone: (225) 219-3443
fax: (225) 219-3474
Parishes Served
Northeast Regional Office
508 Downing Pines Road
Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison,
West Monroe, LA 71292
phone: (318) 362-5439
Morehouse, Ouchita, Richland, Tensas, Union, West Carroll
fax: (318) 362-5448
Kisatchie Central Office
(Located in the Northeast Regional Office Service Area)
2129
Rainbow Drive
Avoyelles, Catahoula, Concordia, Grant, La Salle, Rapides, Winn
Pineville, LA 71360
phone: (318) 487-5656
fax: (225) 325-8115
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, St. John
New Orleans, LA 70123-5230
the Baptist, St. Charles, St. Tammany, Terrebonne, 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, St. John
110 Barataria St.
the Baptist, St. Charles, St. Tammany, Terrebonne, 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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