Form SFN-10980 "Notification for Underground Storage Tanks" - North Dakota

What Is Form SFN-10980?

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

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the North Dakota Department of Health;
  • 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 SFN-10980 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN-10980 "Notification for Underground Storage Tanks" - North Dakota

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FOR STATE USE ONLY:
NOTIFICATION FOR UNDERGROUND STORAGE TANKS
NORTH DAKOTA DEPARTMENT OF HEALTH
Facility ID#:
DIVISION OF WASTE MANAGEMENT - UST PROGRAM
Log ID#:
SFN-10980 (REV: 04/2018)
 First
 Amended
 Closure
I. TYPE OF NOTIFICATION
II. FACILITY INFORMATION (
)
check if new facility name
Facility Name Where Tanks Are Located:
County:
Phone Number:
Facility Mailing Address (or PO Box)
City:
State:
Zip Code:
Facility 911 ADDRESS (REQUIRED):
City
State:
Zip Code:
Facility Latitude and Longitude in Decimal Degrees:
TYPE OF FACILITY
 Gas Station
 Local Government
 Contractor
 Petroleum Distributor
 State Government
 Truck/Transportation
 Air Taxi (Airliner)
 Federal Non-Military Installation
 Utilities
 Aircraft Owner
 Federal Military Installation
 Farm
 Auto Dealership
 Commercial
 Residential
 Railroad
 Industrial
 Other
 Yes
 No
ARE THE TANKS LOCATED ON INDIAN LANDS?
Tribe/Nation:
III. TANK OWNER INFORMATION
Name of Tank Owner:
Phone Number:
Owner Mailing Address:
City:
State:
Zip Code:
Type of Owner:
Federal
State
Local
Commercial
Private
IV. CONTACT PERSON INFORMATION
First Name:
Last Name:
Title:
Phone Number:
Email Address:
Contact Person’s Mailing Address:
City:
State:
Zip Code:
SFN 10980 Rev.: 04/2018
Page 1 of 6
FOR STATE USE ONLY:
NOTIFICATION FOR UNDERGROUND STORAGE TANKS
NORTH DAKOTA DEPARTMENT OF HEALTH
Facility ID#:
DIVISION OF WASTE MANAGEMENT - UST PROGRAM
Log ID#:
SFN-10980 (REV: 04/2018)
 First
 Amended
 Closure
I. TYPE OF NOTIFICATION
II. FACILITY INFORMATION (
)
check if new facility name
Facility Name Where Tanks Are Located:
County:
Phone Number:
Facility Mailing Address (or PO Box)
City:
State:
Zip Code:
Facility 911 ADDRESS (REQUIRED):
City
State:
Zip Code:
Facility Latitude and Longitude in Decimal Degrees:
TYPE OF FACILITY
 Gas Station
 Local Government
 Contractor
 Petroleum Distributor
 State Government
 Truck/Transportation
 Air Taxi (Airliner)
 Federal Non-Military Installation
 Utilities
 Aircraft Owner
 Federal Military Installation
 Farm
 Auto Dealership
 Commercial
 Residential
 Railroad
 Industrial
 Other
 Yes
 No
ARE THE TANKS LOCATED ON INDIAN LANDS?
Tribe/Nation:
III. TANK OWNER INFORMATION
Name of Tank Owner:
Phone Number:
Owner Mailing Address:
City:
State:
Zip Code:
Type of Owner:
Federal
State
Local
Commercial
Private
IV. CONTACT PERSON INFORMATION
First Name:
Last Name:
Title:
Phone Number:
Email Address:
Contact Person’s Mailing Address:
City:
State:
Zip Code:
SFN 10980 Rev.: 04/2018
Page 1 of 6
V. DESCRIPTION OF UNDERGROUND STORAGE TANKS
Note: If there are more than seven underground storage tanks or tank compartments at this location, make additional copies of this
form before filling in any information.
1. TANK INFORMATION
Tank ID
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Estimated total capacity of tank (gallons)
Is the tank compartmented? Y/N
Compartment ID
(if applicable) i.e. 1a, 1b
Size of compartment (gallons)
Is the tank used for heating oil only?
Is the tank used for an emergency power generator?
Is the tank an aboveground tank (AST)?
2. STATUS OF TANK OR COMPARTMENT
Currently In Use
Temporarily Out of Use
Permanently Out of Use
3. INSTALLATION
Date of Installation (mm/dd/yy)
4. SUBSTANCE STORED
Gasoline
Alcohol Blends >15% or E85
Diesel
Biodiesel >20%
Heating Oil
Used Oil
Hazardous Substance
Name of substance or CAS number
Other (specify)
5. TANK MATERIAL
Bare Steel
Cathodically Protected Steel
Epoxy Coated Steel
Fiberglass Reinforced Plastic
Concrete
Unknown
Other (specify)
6. CONSTRUCTION OF TANK
Single-Walled
Double-Walled
Polyethylene Tank Jacket
Lined Interior
Excavation Liner
7. CATHODIC PROTECTION FOR TANKS
Sacrificial Anodes
Impressed Current
Not required
SFN 10980 Rev.: 04/2018
Page 2 of 6
Tank ID
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Compartment ID (if applicable)
8. LEAK DETECTION FOR TANKS AND
COMPARTMENTS
Manual Tank Gauging
Tank Tightness Testing
Automatic Tank Gauging
Interstitial Monitoring
Statistical Inventory Reconciliation
Other method allowed by the state (specify)
VI. DESCRIPTION OF SPILL AND OVERFILL SYSTEM
9. SPILL PREVENTION DEVICE (tank)
Installation date
Capacity of spill bucket (gallons)
Delivery of product less than 25 gallons?
Is containment double-walled?
10. LEAK DETECTION USED ON SPILL BUCKET
Interstitial Monitoring
Tightness Testing
Other method (specify)
11. OVERFILL PREVENTION DEVICE (tank)
Ball Float Valve
High Level Alarm
Automatic Shutoff (flapper valve)
Other method allowed by the state
VII. DESCRIPTION OF PIPING SYSTEM
12. DATE OF PIPING INSTALLATION
13. PIPING MATERIAL
Bare or Galvanized Steel
Cathodically Protected Steel
Fiberglass Reinforced Plastic
Flexible Plastic
Copper
Unknown
Other (specify)
14. CONSTRUCTION OF PIPING
Single-Walled
Double-Walled
Secondary Containment
SFN 10980 Rev.: 04/2018
Page 3 of 6
Tank ID
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Compartment ID (if applicable)
15. CATHODIC PROTECTION FOR PIPING
Sacrificial Anodes
Impressed Current
Not required
16. TYPE OF PIPING SYSTEM
Pressurized
Suction with no valve at tank (safe suction)
Suction with valve at tank
Gravity fed
17. LEAK DETECTION FOR PIPING
Interstitial Monitoring with Sump Alarms
Interstitial Monitoring Visual Monitoring
Annual Line Tightness Testing
Electronic .2 gph Line Leak Detectors
Mechanical 3 gph Line Leak Detectors
Statistical Inventory Reconciliation
Other method allowed by the state (specify)
18. FOR PRESSURIZED PIPING SYSTEMS
Make and Model of Line Leak Detector
Automatic Flow Restriction
Automatic Shut Off Device
Continuous Alarm System (Sump Sensors)
19. PIPING SUMP INFORMATION
Installation date
Capacity of piping sump (gallons)
Is piping sump double-walled?
Does the piping sump have sump alarms?
Is the sump contained?
20. CONSTRUCTION OF PIPING SUMP
Fiberglass
Plastic
Metal
Other (specify)
21. LEAK DETECTION FOR PIPING SUMP
Interstitial Monitoring
Tightness Testing
Other method (specify)
SFN 10980 Rev.: 04/2018
Page 4 of 6
VIII. DESCRIPTION OF DISPENSERS
22. DISPENSER INFORMATION
Dispenser ID
Installation date
Is this a single hose dispenser?
Does this dispenser only use credit card?
Is the dispenser a blender dispenser?
Is this a satellite dispenser?
Does the dispenser have under dispenser
containment?
UNDER DISPENSER CONTAINMENT (UDC)
23.
Capacity of containment (gallons)
Is the containment double-walled?
Does the UDC have sump sensors?
24. CONSTRUCTION OF UDC
Fiberglass
Plastic
Other (specify)
25. LEAK DETECTION USED ON UDC
Interstitial Monitoring
Tightness Testing
Other method (specify)
IX. ADDITIONAL INFORMATION
Tank ID
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
Tank ____
26. FOR TANKS TAKEN OUT OF USE
Date Last Used and Emptied (mm/dd/yy)
)
Date Tank Removed from Ground (mm/dd/yy
Date Closed/Abandoned in Place (mm/dd/yy)
27. CERTIFICATION OF FINANCIAL RESPONSIBILITY
This facility meets the financial responsibility requirements in accordance with Sections 33-24-08-80 through 33-24-08-102 NDAC by:
ND Petroleum Release Compensation Fund
Government
PTRCF ID Number:______________
Railroad
If the owner of this facility owns more than 100 tanks in the United States, this facility meets the financial responsibility requirements
in accordance with Section 33-24-08-83.2b by:
Self-Insured
Letter of Credit
Insurance
Trust Fund
Risk Retention Group
Surety Bond
Guarantee
SFN 10980 Rev.: 04/2018
Page 5 of 6
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