DNR Form 542-1424 "Free Product Recovery Report - Leaking Underground Storage Tank Site Assessment" - Iowa

What Is DNR Form 542-1424?

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

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the Iowa 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 fillable version of DNR Form 542-1424 by clicking the link below or browse more documents and templates provided by the Iowa Department of Natural Resources.

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Download DNR Form 542-1424 "Free Product Recovery Report - Leaking Underground Storage Tank Site Assessment" - Iowa

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Print Form
Free Product Recovery Report
Leaking Underground Storage Tank Site Assessment
for the Iowa Department of Natural Resources
SITE IDENTIFICATION
LUST No.
UST Registration No.
Site Name:
Site Address:
City:
RESPONSIBLE PARTY IDENTIFICATION
Name:
Street:
City:
State:
Zip Code:
Submittal Date:
STATEMENT OF CERTIFICATION
I,
, Groundwater Professional Certification No.
, am familiar with all
Applicable requirements of Iowa Code § 455B.474 and all rules and procedures adopted thereunder including, but not
limited to, Chapter 567-135 and the Department of Natural Resources’ Free Product Recovery Report guidance.
Based on my knowledge of those documents and information I have prepared and reviewed regarding this site, UST
Registration No.
, LUST No.
, I certify that this document is complete and
accurate as provided in 567 IAC 135.9(11)”c) and meets the applicable requirements of the Free Product Recovery
Report.
Print: Name/Address of Certified Groundwater Professional
Signature:
Phone:
Date:
I certify that I have reviewed this document and attachments for submittal to the Iowa Department of Natural Resources.
Print Name of Responsible Party
Signature- Responsible Party
Official IDNR Use Only
Date Received:
Comment Letter Date:
Y
/
N
Reviewer:
Approved:
08/2012 cmz
DNR Form 542-1424
Print Form
Free Product Recovery Report
Leaking Underground Storage Tank Site Assessment
for the Iowa Department of Natural Resources
SITE IDENTIFICATION
LUST No.
UST Registration No.
Site Name:
Site Address:
City:
RESPONSIBLE PARTY IDENTIFICATION
Name:
Street:
City:
State:
Zip Code:
Submittal Date:
STATEMENT OF CERTIFICATION
I,
, Groundwater Professional Certification No.
, am familiar with all
Applicable requirements of Iowa Code § 455B.474 and all rules and procedures adopted thereunder including, but not
limited to, Chapter 567-135 and the Department of Natural Resources’ Free Product Recovery Report guidance.
Based on my knowledge of those documents and information I have prepared and reviewed regarding this site, UST
Registration No.
, LUST No.
, I certify that this document is complete and
accurate as provided in 567 IAC 135.9(11)”c) and meets the applicable requirements of the Free Product Recovery
Report.
Print: Name/Address of Certified Groundwater Professional
Signature:
Phone:
Date:
I certify that I have reviewed this document and attachments for submittal to the Iowa Department of Natural Resources.
Print Name of Responsible Party
Signature- Responsible Party
Official IDNR Use Only
Date Received:
Comment Letter Date:
Y
/
N
Reviewer:
Approved:
08/2012 cmz
DNR Form 542-1424
Free Product Recovery Information
Tabulate the free product and groundwater volumes removed from each well. List each extraction event chronologically with the
oldest data first. The results for all events must be provided. Give all elevations as feet Above Sea Level (ASL).
Ground
surface elevation must be reported to the nearest 0.1 foot. Top of casing elevation, static water elevations, and free product
thickness must be reported to the nearest 0.01 foot. Volume of free product and groundwater removed must be reported to the
nearest 0.1 gallon. A separate sheet should be used for each recovery well.
Well Number:
Ground Surface Elevation:
Top of Casing Elevation:
Date Sampled
Static Groundwater
Free Product
Volume of Free Product
Volume of Groundwater
Level (feet ASL)
Thickness (feet)
Removed (gallons)
Removed (gallons)
08/2012 cmz
DNR Form 542-1424
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