Form SFN16932 "Underground Storage Tank Closure Form" - North Dakota

What Is Form SFN16932?

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, 2007;
  • 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 fillable version of Form SFN16932 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form SFN16932 "Underground Storage Tank Closure Form" - North Dakota

820 times
Rate (4.5 / 5) 41 votes
FOR STATE USE ONLY
UNDERGROUND STORAGE TANK CLOSURE FORM
Facility ID Number
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT - UST PROGRAM
þÿClear Fields
SFN 16932 (4-2007)
This form is provided as guidance to tank owners/operators and others to assist in the observation of an underground storage tank closure. NDAC Article 33-
24-08 requires tank owners and operators to assess an underground storage tank site for the presence of a release whenever an underground storage tank
system is closed. It is the legal duty of the tank owner and operator to report ANY evidence of petroleum contamination to the Division of Waste Management.
1. OBSERVER INFORMATION (Please Print)
Observer (Owner, Operator, Contractor, etc.)
Position
Mailing Address
City
State
Zip Code
Organization
Telephone Number
Weather Conditions
Closure Time
Closure Date
Signature
Printed Name
2. TANK INFORMATION
Name of Tank Owner
Contact Person
Title
Telephone Number
Tank Location Name
Tank Location Address
City
State
Zip Code
Excavation Contractor
Telephone Number
Address
City
State
Zip Code
Tank
Size
Contents
Corrosion - Describe
Evidence of Leakage
Year Installed
Number
(Gallons)
(Product Last Stored)
(Rust, Pitting, Holes, etc.)
(Holes, Spills, Overfills)
3. SOIL AND GROUNDWATER CONDITIONS WITHIN THE EXCAVATION
Petroleum Contamination Detected
Petroleum Odors
Soil Stained by Petroleum
Sheen on Water Mixed with Soil
Petroleum Product on Groundwater in Excavation
Were samples analyzed for petroleum contamination
Soil Type
Pictures Taken
Tank Closure Completed By
Tank Disposal Location
Contaminated Soil Disposal Completed By
Contaminated Soil Disposal Location and Amount (Cubic Yards)
Contaminated Water Disposal Completed By
Contaminated Water Disposal Location and Amount (Gallons)
FOR STATE USE ONLY
UNDERGROUND STORAGE TANK CLOSURE FORM
Facility ID Number
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT - UST PROGRAM
þÿClear Fields
SFN 16932 (4-2007)
This form is provided as guidance to tank owners/operators and others to assist in the observation of an underground storage tank closure. NDAC Article 33-
24-08 requires tank owners and operators to assess an underground storage tank site for the presence of a release whenever an underground storage tank
system is closed. It is the legal duty of the tank owner and operator to report ANY evidence of petroleum contamination to the Division of Waste Management.
1. OBSERVER INFORMATION (Please Print)
Observer (Owner, Operator, Contractor, etc.)
Position
Mailing Address
City
State
Zip Code
Organization
Telephone Number
Weather Conditions
Closure Time
Closure Date
Signature
Printed Name
2. TANK INFORMATION
Name of Tank Owner
Contact Person
Title
Telephone Number
Tank Location Name
Tank Location Address
City
State
Zip Code
Excavation Contractor
Telephone Number
Address
City
State
Zip Code
Tank
Size
Contents
Corrosion - Describe
Evidence of Leakage
Year Installed
Number
(Gallons)
(Product Last Stored)
(Rust, Pitting, Holes, etc.)
(Holes, Spills, Overfills)
3. SOIL AND GROUNDWATER CONDITIONS WITHIN THE EXCAVATION
Petroleum Contamination Detected
Petroleum Odors
Soil Stained by Petroleum
Sheen on Water Mixed with Soil
Petroleum Product on Groundwater in Excavation
Were samples analyzed for petroleum contamination
Soil Type
Pictures Taken
Tank Closure Completed By
Tank Disposal Location
Contaminated Soil Disposal Completed By
Contaminated Soil Disposal Location and Amount (Cubic Yards)
Contaminated Water Disposal Completed By
Contaminated Water Disposal Location and Amount (Gallons)
SFN 16932 (4-2007)
Page 2 of 2
The Division of Waste Management must be notified immediately of any evidence of
petroleum contamination. The 24-Hour Emergency Leak or Spill telephone number is:
701-328-2121 or 1-800-472-2121 (in-state only)
During business hours (Monday - Friday) call: 1-701-328-5166
4. SKETCH THE PROPERTY SITE AND TANK LOCATION(S) IN THE SPACE PROVIDED BELOW.
NORTH
WEST
EAST
SOUTH
5. ADDITIONAL COMMENTS AND DETAILS (i.e., PID readings, site observations, state or local inspector(s), etc.)
Please fill out this form as completely as possible and send to:
North Dakota Department of Health
Division of Waste Management
918 E Divide Ave., 3rd Fl.
Bismarck, ND 58501-1947
Telephone: 701-328-5166
Fax Number: 701-328-5200
Website: www.ndhealth.gov/wm
Page of 2