Form UST-264 "Document Submittal Form" - Arizona

What Is Form UST-264?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Arizona Department of Environmental Quality;
  • 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 UST-264 by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

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Download Form UST-264 "Document Submittal Form" - Arizona

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ADEQ use only
UST-LUST
1110 West Washington Street
Phoenix, Arizona 85007
USTCAS@azdeq.gov
DOCUMENT SUBMITTAL FORM
Do not submit reports in a three ring binder.
Person Responsible for Submitting Document – check all that apply:
☐ UST Owner ☐ UST Operator ☐ Property Owner
☐ Political Subdivision
☐ ADEQ State Lead
Company Name (same as AZ Corp. Commission filing):
_______________________________________________
UST owner/operator ID No: _________ Authorized Individual: ☐ Mr. ☐ Ms. _________________________________
Mailing Street Address: ___________________________________________________________________________
City:
_________________________________________
State:
_____________
Zip Code: _____________
Daytime Telephone:
_____________________________
Email:
_____________________________________
Identify the Submitted Document(s) – check all that apply
Other (describe): __________________________
☐ 14 day report
☐ 90 day report
Suspected release(s):
Confirmed release(s):
☐ 14 day report
☐ Free product report
☐ 90 day report/initial site characterization report (ISCR)
☐ LUST site classification form
☐ Site characterization report (SCR)
☐ Revised SCR
☐ Periodic site status report (PSSR)
☐ Corrective action plan (CAP)
☐ Revised CAP
☐ Tier 3 risk evaluation
☐ eCSM update
☐ Corrective action completion report (LUST closure request)
☐ Corrective action completion report (alternative groundwater LUST closure request)
☐ Other (describe): ______________________________________
UST: ☐ UST Closure Report ☐ Baseline Assessment Report ☐ Other (describe): ______________________________
Release Information
Assigned LUST number (if not available, put the date the release was reported to ADEQ): _______________________
Facility Information
ADEQ Facility ID:
0-0____________
Facility Name:
_______________________________________________
Facility Street Address:
___________________________________________________________________________
City:
______________________________ Zip Code:
_____________
County:
_____________________
Form UST-264 (Revised October 2019)
ADEQ Document Submittal Form
Page 1 of 2
ADEQ use only
UST-LUST
1110 West Washington Street
Phoenix, Arizona 85007
USTCAS@azdeq.gov
DOCUMENT SUBMITTAL FORM
Do not submit reports in a three ring binder.
Person Responsible for Submitting Document – check all that apply:
☐ UST Owner ☐ UST Operator ☐ Property Owner
☐ Political Subdivision
☐ ADEQ State Lead
Company Name (same as AZ Corp. Commission filing):
_______________________________________________
UST owner/operator ID No: _________ Authorized Individual: ☐ Mr. ☐ Ms. _________________________________
Mailing Street Address: ___________________________________________________________________________
City:
_________________________________________
State:
_____________
Zip Code: _____________
Daytime Telephone:
_____________________________
Email:
_____________________________________
Identify the Submitted Document(s) – check all that apply
Other (describe): __________________________
☐ 14 day report
☐ 90 day report
Suspected release(s):
Confirmed release(s):
☐ 14 day report
☐ Free product report
☐ 90 day report/initial site characterization report (ISCR)
☐ LUST site classification form
☐ Site characterization report (SCR)
☐ Revised SCR
☐ Periodic site status report (PSSR)
☐ Corrective action plan (CAP)
☐ Revised CAP
☐ Tier 3 risk evaluation
☐ eCSM update
☐ Corrective action completion report (LUST closure request)
☐ Corrective action completion report (alternative groundwater LUST closure request)
☐ Other (describe): ______________________________________
UST: ☐ UST Closure Report ☐ Baseline Assessment Report ☐ Other (describe): ______________________________
Release Information
Assigned LUST number (if not available, put the date the release was reported to ADEQ): _______________________
Facility Information
ADEQ Facility ID:
0-0____________
Facility Name:
_______________________________________________
Facility Street Address:
___________________________________________________________________________
City:
______________________________ Zip Code:
_____________
County:
_____________________
Form UST-264 (Revised October 2019)
ADEQ Document Submittal Form
Page 1 of 2
UST Owner Information
(if different than Person Responsible for Submitting Document)
Company Name (same as AZ Corp. Commission filing):
_________________________________________________
UST owner/operator ID No: __________ Authorized Individual: ☐ Mr. ☐ Ms. ________________________________
Mailing Street Address: ____________________________________________________________________________
City:
_________________________________________
State:
_____________
Zip Code:
_____________
Daytime Telephone:
_____________________________
Email:
_______________________________________
UST Operator Information
(if different than Person Responsible for Submitting Document)
Company Name (same as AZ Corp. Commission filing):
_________________________________________________
UST owner/operator ID No: ________ Authorized Individual: ☐ Mr. ☐ Ms. __________________________________
Mailing Street Address: ___________________________________________________________________________
City:
_________________________________________
State:
_____________
Zip Code:
_____________
Daytime Telephone:
_____________________________
Email:
_______________________________________
Property Owner Information
(if different than Person Responsible for Submitting Document)
Company Name (same as AZ Corp. Commission filing):
______________________________________________
UST owner/operator ID No: ______ Authorized Individual: ☐ Mr. ☐ Ms. ____________________________________
Mailing Street Address:
________________________________________________________________________
City:
________________________________________
State:
____________
Zip Code:
____________
Daytime Telephone:
___________________________
Email:
______________________________________
Seal of Arizona Professional Registrant (required for submittals that include professional judgment, design, analysis, or
conclusions, including original plans, drawings, maps, plats, reports, written opinions, specifications, and calculations):
Certification Statement of UST Owner, UST Operator, or Property Owner (under A.R.S. § 49-1016.C)
“I hereby certify, under penalty of law, that this submittal and all attachments are, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of a fine and imprisonment for knowing violations.”
Signature of Authorized Individual
Title
Date
Form UST-264 (Revised October 2019)
ADEQ Document Submittal Form
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