Instructions for State Form 56554 "Underground Storage Tank Systems Closure Report" - Indiana

This document contains official instructions for State Form 56554, Underground Storage Tank Systems Closure Report - a form released and collected by the Indiana Department of Environmental Management. An up-to-date fillable State Form 56554 is available for download through this link.

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INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
Instructions for State Form 56554 (5-19)
Underground Storage Tank Systems Closure Report
May 2019
This Underground Storage Tank Systems Closure Report form should be completed for any
location that has permanently closed registered tanks with IDEM. This form should be submitted
with an Underground Storage Tank Closure Report (which should include lab data, site maps,
disposal documentation, etc. as required by 329 IAC 9-6).
Complete each section fully unless specified below, even if the UST Owner, UST Operator, and
Property Owner are the same entities. The sections shall be completed fully with the entity
information and “same as” will not be accepted. IDEM has found that past forms completed with
“same as” often caused confusion later when trying to determine eligible party information for
the Excess Liability Trust Fund. If any required portions of this form are not completed, a Notice
of Deficiency indicating deficient regulatory obligations will be sent.
Agency Interest ID Number
Enter the Agency Interest ID number that is assigned to this location. If the Agency Interest ID
number is unknown, then leave blank.
Facility ID Number
Enter the Facility ID number that is assigned to this location.
Owner Entity Number:
Enter the Owner Entity Number that is assigned to the company or individual who is the UST
Owner at the facility. If the Entity Number is unknown, then leave blank.
A. Type of closure
Mark the type of closure that was performed for Tank(s), Piping and Dispenser(s). Enter the
number of tanks, piping lines and dispensers closed. If only piping and dispenser(s) are closed,
a closure report is not necessary. However, if piping and dispensers are being replaced, a
Notification for Underground Storage Tanks, State Form 45223, UST system modification
should be submitted.
B. Facility Name / Location
Enter the current name of the business, the full 911 address, and telephone number for the
facility. The parcel number is required and may be found on the property report or property card
available on most county assessor websites, or the county assessor's office can be contacted
for the information. IDEM requires the geographic location of the facility in Latitude/Longitude -
Decimal Degrees (to six significant digits). Example: Latitude: 39.769063, Longitude: -
86.164815. Geographic coordinates may be determined using 1) online mapping applications,
pg. 1
INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
Instructions for State Form 56554 (5-19)
Underground Storage Tank Systems Closure Report
May 2019
This Underground Storage Tank Systems Closure Report form should be completed for any
location that has permanently closed registered tanks with IDEM. This form should be submitted
with an Underground Storage Tank Closure Report (which should include lab data, site maps,
disposal documentation, etc. as required by 329 IAC 9-6).
Complete each section fully unless specified below, even if the UST Owner, UST Operator, and
Property Owner are the same entities. The sections shall be completed fully with the entity
information and “same as” will not be accepted. IDEM has found that past forms completed with
“same as” often caused confusion later when trying to determine eligible party information for
the Excess Liability Trust Fund. If any required portions of this form are not completed, a Notice
of Deficiency indicating deficient regulatory obligations will be sent.
Agency Interest ID Number
Enter the Agency Interest ID number that is assigned to this location. If the Agency Interest ID
number is unknown, then leave blank.
Facility ID Number
Enter the Facility ID number that is assigned to this location.
Owner Entity Number:
Enter the Owner Entity Number that is assigned to the company or individual who is the UST
Owner at the facility. If the Entity Number is unknown, then leave blank.
A. Type of closure
Mark the type of closure that was performed for Tank(s), Piping and Dispenser(s). Enter the
number of tanks, piping lines and dispensers closed. If only piping and dispenser(s) are closed,
a closure report is not necessary. However, if piping and dispensers are being replaced, a
Notification for Underground Storage Tanks, State Form 45223, UST system modification
should be submitted.
B. Facility Name / Location
Enter the current name of the business, the full 911 address, and telephone number for the
facility. The parcel number is required and may be found on the property report or property card
available on most county assessor websites, or the county assessor's office can be contacted
for the information. IDEM requires the geographic location of the facility in Latitude/Longitude -
Decimal Degrees (to six significant digits). Example: Latitude: 39.769063, Longitude: -
86.164815. Geographic coordinates may be determined using 1) online mapping applications,
pg. 1
INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
2) handheld GPS receivers, 3) mobile apps for smartphones and tablets with GPS capability or
4) traditional surveying methods.
C. UST Owner
Enter information regarding the company or individual that is the UST Owner. UST Owner
updates cannot be processed as a part of a closure report. If an UST Owner update is
necessary, please complete and submit the Notification for Underground Storage Tanks, State
Form 45223 prior to submitting in your closure report.
D. UST Operator
Enter information regarding the company or individual that is the UST Operator. UST Operator
updates cannot be processed as a part of a closure report. If an UST Operator update is
necessary, please complete and submit the Notification for Underground Storage Tanks, State
Form 45223 prior to submitting in your closure report.
E. Property Owner
Enter information regarding the company or individual that is the Property Owner. Property
Owner updates cannot be processed as a part of a closure report. If a Property Owner update
is necessary, please complete and submit the Notification for Underground Storage Tanks,
State Form 45223 prior to submitting in your closure report.
F. Contractor & Certified Individual Compliance Certification
Enter information regarding the contractor or consultant that performed the work. Specify the
certified individual who is authorized to verify the work on the UST system complies with
regulatory requirements, and the individual’s Indiana Department of Homeland Security/Division
of Fire and Building Safety certification number. The certified individual must sign and date their
signature. Electronic signatures are accepted and original wet ink signatures are not required.
G. UST Owner Certification
List the UST Owner’s authorized representative name, title and company name (if the UST
owner is not an individual). The authorized representative must sign and date their signature.
Electronic signatures are accepted and original wet ink signatures are not required. If the UST
owner is an individual and not a company, the UST owner must sign the certification.
H. UST Operator Certification
List the UST Operator’s authorized representative name, title and company name (if the UST
operator is not an individual). The authorized representative must sign and date their signature.
Electronic signatures are accepted and original wet ink signatures are not required. If the
operator is an individual and not a company, the UST operator must sign the certification.
I. Potentially Interested Parties
pg. 2
INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
This section must be completed to include the email address of the registered agent for any
company listed on this form that is registered with the Indiana Secretary of State. UST Owners,
UST Operators, and Property Owners may also include other interested parties, such as
additional contacts at the company or contacts at an environmental consulting firm. IDEM will
use these e-mail addresses, along with the owners and operators identified in sections above,
to send out notices of deficiency or to respond to inquiries about this site.
J. LUST Incident Information
List any LUST Incident number (if applicable) and date the incident was reported in this section.
K. UST Information
This section must completed with the following information: the number of regulated tanks
onsite before the closure and any additional USTs discovered on site. In the table you will put
the tank number, capacity, substance last stored in the tank(s), construction material of the
tank(s), installation date, date last used, closure date and closure type. If the tank is part of a
compartmented tank mark the yes checkbox.
If applicable, include an in-place closure justification in the space provided.
L. Piping Information
This section must be completed with the following information if piping was removed during the
closure of the UST System: piping number (associated with the number of the UST that was
removed), piping run length (if you removed piping, you must include the length of the piping
run), substance, construction material, install date, last used date, closure date, closure type
and the UST number it was associated with. If the piping was attached to a compartmented
tank, select which compartment it was associated with.
Include the number of elbows and connectors.
If applicable, include an in-place closure justification in the space provided.
M. Dispenser Information
This section must be completed with the following information if dispenser(s) were removed
during the closure of the UST system: dispenser number, product dispensed, install date, last
used date, removal date, replacement date (if applicable) and closure type.
N. Storage and Disposal
Indicate the method of liquid and/or sludge storage when the tanks were emptied. Indicate the
method of liquid and/or sludge disposal. Indicate the location of UST system components
storage/disposal.
O. UST Removal
pg. 3
INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
Complete this section if the tank(s) and/or piping were removed during the closure. You must
include the following information: what was done with the tank(s), amount of backfill material
initially removed, amount of material that was over excavated if applicable, whether free product
was present in the tank pit or piping runs, whether bedrock was encountered, and whether all
contaminated material was excavated (if it was not, please explain why it was not removed),
what material was used to backfill the excavation after tank removal.
If water was encountered, you must include the following information: the amount of water
removed from the excavation if applicable, whether the water was sampled (if not, please
explain why it was not sampled) and the method of water disposal. If contamination above an
applicable screening level was encountered, then based on visual inspection of the UST
components during removal indicate which component(s) appear to have failed causing the
contamination. Check all boxes that apply in the table. Provide specific details about what was
observed. If “other” was checked, please explain. Based on the answers, please check what
action or process appears to have caused the contamination.
P. In-Place Closure
Complete this section only if the tank and/or piping were not removed during closure. You must
include the following information: what inert solid material was used to fill the tank(s) and/or
piping, whether water was encountered in the soil boring(s), and whether bedrock was
encountered.
Q. Laboratory Information
This section must be completed to include the name of the Laboratory where samples were
analyzed and check the appropriate box (soil or water samples).
R. Soil Screening Levels and Analytical Results
This section must be completed to include information regarding type of backfill originally used
during the installation of the UST system, native soil type description, number of samples taken
and whether any contaminant concentration for any soil sample after removal, in-place closure,
or over excavation was above Migration to Groundwater screening levels (MTGSL) for any
Potential Petroleum Contaminants (PPC) or Chemical of Concern (COC).
S. Ground Water Screening Levels and Analytical Results
Complete this section with the number of samples taken and whether any contaminant
concentration for any water sample after removal, in-place closure, or over excavation was
above the tap water screening levels (TWSL) for any Potential Petroleum Contaminants (PPC)
or Chemical of Concern (COC).
T. Excavated Soil/Stockpiled Soil Analytical Results
pg. 4
INDIANA DEPARTMENT
ENVIRONMENTAL MANAGEMENT
OF
State Form Instructions 56554 (R2 / 5-19)
Complete this section to include the number of samples taken and whether any contaminant
concentration for any excavated/stockpiled soil sample after removal, in-place closure, or over
excavation was above Migration to Groundwater screening levels (MTGSL) for any Potential
Petroleum Contaminants (PPC) or Chemical of Concern (COC).
U. Historic Operations Information
Complete this section with owners and operators for the last twenty-five years. Also indicate the
type of business run from this facility for the last twenty-five years.
V. Site Information
Check all boxes that apply for site coverage. If “other” was checked, please explain.
Include information about site proximity to both human and environmentally sensitive areas,
such as residences, schools, wells, well fields, or wellhead protection areas described in 327
IAC 8-4.1.
W. Previously Closed UST Systems
Complete this section with information about any previously closed USTs.
X. Closure Report Document
The closure report must be submitted in the order of 1-12 indicated in this section. The form will
be first and does not need to be numbered. Then number the remaining items 2 – 12 and
include the item in the appropriate order for ease of verifying all required information is included.
Document Submittal Guidelines
Submit form to the
USTRegistration@idem.IN.gov
Subject line: Closure: FID # ____
Save Document: CL_FID(insertnumber)_(yyyymmdd)
File names for electronic documents must not include any symbols, i.e.:
exclamation point
(!),
pound symbol
(#),
dollar sign
($),
percent sign
(%),
ampersand
(&),
asterisk
(*),
single quote/apostrophe (') or double quotes
("),
at
symbol
(@),
slash (/) or backslash (/)
If a document is over 10MB, please mail a CD:
IDEM
OLQ – UST Branch
100 N Senate Ave, IGCN 1101
Indianapolis, IN 46204-2251
pg. 5
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