Form ECY020-94 "Permanent Closure Notice" - Washington

What Is Form ECY020-94?

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

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Washington State Department of Ecology;
  • 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 ECY020-94 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY020-94 "Permanent Closure Notice" - Washington

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UST ID #: __________
P
C
N
ERMANENT
LOSURE
OTICE
County: __________
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
This notice certifies that permanent closure activities were performed
and conducted in accordance with Chapter 173-360A WAC. Instructions
are found on the back page.
I. UST F
II. O
/O
I
ACILITY
WNER
PERATOR
NFORMATION
Facility Compliance Tag #:
Owner/Operator Name:
UST ID #:
Business Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Phone:
Email:
III. C
UST D
ERTIFIED
ECOMMISSIONER
Company Name:
Service Provider Name:
Address:
Certification Type:
City:
State:
Zip:
Cert. No.:
Exp. Date:
Provider Phone:
Provider Email:
Provider Signature:
Date:
IV. T
I
ANK
NFORMATION
C
M
LOSURE
ETHOD
L
S
AST
UBSTANCE
T
ID
T
C
C
D
ANK
ANK
APACITY
LOSURE
ATE
S
TORED
removal
closed-in-place
change-in-service
V. R
S
EQUIRED
IGNATURE
Signature acknowledges UST(s) comply with UST regulation WAC 173-360A-0810 Permanent Closure Requirements
.
Date
Signature of Tank Owner/Operator or Authorized
Print or Type Name
Representative
ECY 020-94 (Revised October 2018)
UST ID #: __________
P
C
N
ERMANENT
LOSURE
OTICE
County: __________
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
This notice certifies that permanent closure activities were performed
and conducted in accordance with Chapter 173-360A WAC. Instructions
are found on the back page.
I. UST F
II. O
/O
I
ACILITY
WNER
PERATOR
NFORMATION
Facility Compliance Tag #:
Owner/Operator Name:
UST ID #:
Business Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Phone:
Email:
III. C
UST D
ERTIFIED
ECOMMISSIONER
Company Name:
Service Provider Name:
Address:
Certification Type:
City:
State:
Zip:
Cert. No.:
Exp. Date:
Provider Phone:
Provider Email:
Provider Signature:
Date:
IV. T
I
ANK
NFORMATION
C
M
LOSURE
ETHOD
L
S
AST
UBSTANCE
T
ID
T
C
C
D
ANK
ANK
APACITY
LOSURE
ATE
S
TORED
removal
closed-in-place
change-in-service
V. R
S
EQUIRED
IGNATURE
Signature acknowledges UST(s) comply with UST regulation WAC 173-360A-0810 Permanent Closure Requirements
.
Date
Signature of Tank Owner/Operator or Authorized
Print or Type Name
Representative
ECY 020-94 (Revised October 2018)
I
NSTRUCTIONS
P
C
N
ERMANENT
LOSURE
OTICE
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
I
NSTRUCTIONS
This form must be completed and submitted within thirty days of completing permanent closure activities to the
following address:
Dept. of Ecology
UST Section
PO Box 47655
Olympia, WA 98504-7655
I./II.
UST Facility and Owner/Operator: Fill out these sections completely. If you do not know your
UST ID number, include the facility compliance tag number. If all tanks at the site are permanently
closed, the facility compliance tag must be returned with this notice.
III.
UST Decommissioner: It is the responsibility of the ICC-certified Decommissioner to follow proper
tank closure procedures in accordance with WAC 173-360A-0810. The Decommissioner signature
certifies these procedures were followed.
Tank Information: Use the same Tank IDs that are listed on the facility’s Business License. List
IV.
the last substance stored in each tank, the tank sizes, the method by which the tank is being closed,
and the date closure activities were conducted. All closure methods require a site assessment be
conducted in accordance with Ecology’s Guidance for Site Checks and Site Assessments for
Underground Storage Tanks.
Required Signature: The owner and/or operator’s signature is required. Also, the owner and/or
V.
operator is responsible for reporting confirmed releases to Ecology within 24 hours.
All confirmed releases must be reported to Ecology by the owner immediately and by service providers
within 72 hours of the discovery of the condition. If the owner or operator is not immediately available, the
report should be made directly to Ecology.
Be sure to contact your local fire marshal and other local jurisdictions. They may have other codes and
regulations that apply to a permanent tank closure.
Further questions? Please contact your regional office below and ask for a tank inspector to assist you.
Regional Office
Counties Served
Central (509) 575-2490
Benton, Chelan, Douglas, Kittitas, Klickitat, Okanogan, Yakima
Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant, Lincoln,
Eastern (509) 329-3400
Pend Oreille, Spokane, Stevens, Walla Walla, Whitman
HQ (360) 407-7170
Federal facilities in Western Washington
Northwest (425) 649-7000
Island, King, Kitsap, San Juan, Skagit, Snohomish, Whatcom
Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Lewis, Mason,
Southwest (360) 407-6300
Pacific, Pierce, Skamania, Thurston, Wahkiakum
or find a complete list of UST inspectors at:
www.ecy.wa.gov/programs/tcp/ust-lust/people.html
ECY 020-94 (Revised October 2018)
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