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DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION 45 Mars Hill Cyril E. King Airport Frederiksted Terminal Building, 2nd Floor St. Croix, VI 00840 St. Thomas, VI 00802 (340) 773-1082 (340) 774-3320 APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANK FACILITY 1. PROPOSED METHOD OF CLOSURE: □ REMOVAL □ CLOSURE IN PLACE I. FACILITY / SITE INFORMATION 2. SCHEDULED CLOSURE DATE _________________________ □ APPLICATION FEE $500 (Acct No. RV 4421) (Must be submitted 45 days prior to installation) PARCEL ID #:__________________________________________ FACILITY ID#: ___________________________________ BUSINESS NAME PHONE PHYSICAL ADDRESS MAILING ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE II. PROPERTY OWNER INFORMATION 3. PROPERTY OWNER NAME PHONE MAILING ADDRESS CITY STATE ZIP CODE III. TANK OWNER INFORMATION 4. TANK OWNER NAME PHONE MAILING ADDRESS CITY STATE ZIP CODE 5. □ Notification Form (EPA Form 7530-1) Attached 6. Total number of tanks to be closed____________ NOTE: UST SYSTEMS INCLUDE TANK AND ALL ASSOCIATED PIPING. ( ) APPROVED ( ) DISSAPPROVED Date permit issued: DPNR-UST-FORM C (11/03) 1 of 3 SAMPLING PROTOCOL: The tank owner/authorized representative is responsible for all sampling analyses and associated costs. • For tank systems that are to be removed. The excavation shall be exposed prior to the scheduled inspection and sampling points identified by the Department of Planning and Natural Resource-Division of Environmental Protection (DPNR-DEP) inspector. Sampling is required for both tank and piping. The tank and piping must remain in the excavation until the DEP Inspector approves the removal. • Tank systems to be closed in place. Submit an alternate plan, which must include soil sampling, reason for closing the tank system in place and type of material to be used to fill the tank. Soil sampling and/or hydrostatic testing is also required for piping closures. Tank system closure in place will only be considered after evaluating the risks and hazards if the tank system were removed. 7. Description of tanks to be closed: TANK NO. CAPACITY DATE INSTALLED TANK COMPOSITION TANK PRESENTLY IN USE? MATERIALS STORED IN TANK 8. Has the tank system ever failed or leaked? □ YES □ NO 9. Reason for tanks to be closed: □ Failure to meet current USVI/Federal requirements □ Replacement of existing tanks □ Tank system failure, describe _______________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ □ Other, describe ______________________________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 10. Previous owners and operators of the tanks: Dates Owner/Operator __________________________________ _____________________________________________________________ __________________________________ _____________________________________________________________ __________________________________ _____________________________________________________________ __________________________________ _____________________________________________________________ __________________________________ _____________________________________________________________ __________________________________ _____________________________________________________________ 11. Is the UST site located in an area deemed extremely vulnerable to groundwater contamination, such as Wellhead Protection Areas? □ YES □ NO 12. Are there any public water wells or private water wells or other source of groundwater within 1000 ft. of the UST site? □ YES □ NO 2 of 3 13. Provide the results of a 1,000 ft. survey for water supply wells in the following table. (Contact Groundwater Program at DPNR-DEP for information (340) 773-1082-St. Croix, (340) 774-3320-St. Thomas/St. John) Name of Owner of Public Water Supply Well Distance from UST Site Depth of Well Status: Active or Inactive? 14. Indicate the current on-site land use and the most likely future land use. (Contact Comprehensive & Coastal Zone Planning at DPNR for information (340) 773-1082-St. Croix, (340) 774-3320-St. Thomas/St. John) Current On-Site Land Use Most Likely Future On-Site Land Use Residential Residential Commercial Commercial Other Other Describe: Describe: 15. Disposal site of tank: ___________________________________________________________________________________ _______________________________________________________________________________________________________ Note: You must inform DEP of the physical address of where the tank and piping is to be disposed. Plans will not be approved without this information. 16. Attach ( 3 ) Copies of Plans Showing The Following: 1. Property lines, site address, scale, north arrow 2. Location of all existing structures. 3. Location of all existing underground storage tank facilities. 4. Location of underground storage tanks and piping to be closed. 5. Location of underground utility lines and vaults. 3 of 3 General Requirements Application for Permit to Close UST Facility 1. Required Inspection-Permit To Close: (A representative from DEP must be on site at the time the tank(s) are closed) A. TANK SYSTEM CLOSURE BY REMOVAL: o The excavation shall be exposed prior to the scheduled inspection. The tank owner/authorized representative on site must submit a uniform hazardous waste manifest demonstrating that the tank has been properly decontaminated. A combustible gas instrument and soil sampling equipment must be on site. The DEP Inspector will identify sampling points. The tank and piping must remain in the excavation until DEP approves the removal. a. Attach a topographic map showing the location of the facility and a general site map showing the area surrounding the UST site. b. Attach plan and sectional views of the excavation and include the following: 1. All appropriate excavation dimensions. 2. All soil sample locations and depths using an appropriate method of identification. 3. Location of areas of visible contamination. 4. Former location of tank(s), including depth, with tank Identification Number. c. Is the groundwater more than 5 feet below the bottom of the excavation? □ YES □ NO If no, provide the depth from the ground surface to the groundwater table. Feet:__________________________ Indicate method used to determine water table depth: 1. Excavation extended 5 feet below base of pit: □ YES □ NO 2. Boring or monitoring well: □ YES □ NO 3. Topographic features (Method must be approved by ADEM prior to use): □ YES □ NO d. Was there a notable odor found in the excavation? □ YES □ NO If yes, (1) The odor was (mild)(strong)(other) describe:_______________________________________________________________________ (2) The odor indicates what type of product: (gasoline)(diesel) (waste oil)(kerosene)(other) describe:______________________________________________________________________________ e. Was there water in the excavation? □ YES □ NO If yes, how was it handled? 1. One time discharge to sanitary sewer with local approval? □ YES □ NO 2. Hauled to facility capable of treating constituents of petroleum products in water? □ YES □ NO 3. Hauled to local POTW with local approval? □ YES □ NO 4. Treated on-site with NPDES approved discharged? □ YES □ NO 5. Other? Explain:__________________________________________________________________________________ f. Was free product found in the excavation? □ YES □ NO If yes, (1) How was free product handled? Describe:____________________________________________________________________________ (2) What was the measured thickness of free product?____________________________________________________________________ g. Were visible holes noted in the tank(s)? □ YES □ NO If yes, Indicate which tanks(s) by the Unique Tank Number: ____________________________________________________________________ 1 of 3 Also, describe the location(s) and provide general description as to the size and number of holes for above noted tanks, (Example: 3 square feet of pinholes or 3 inch diameter hole): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ h. Describe the soil type and thickness of all soil layers encountered in the excavation: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ i. Was the excavation backfilled? □ YES □ NO If yes, provide the date of backfilling:__________________________________________________________________________________ B. TANK SYSTEM CLOSURE IN PLACE: o Soil sampling for tank(s) and piping. o After approval of the alternate plan, the tank owner/authorized representative on site shall submit a uniform hazardous waste manifest demonstrating that the tank has been properly decontaminated. The DEP Inspector shall verify that the tank system has been properly emptied and will witness the filling with an approved inert substance. Piping must be closed at the same time as the tank. a. Attach a topographic map showing the location of the facility and a general site map showing the area surrounding the UST site. b. Attach plan and sectional views of the excavation and include the following: 1. All appropriate excavation dimensions. 2. All soil sample locations and depths using an appropriate method of identification. 3. Location of areas of visible contamination. 4. Former location of tank(s), including depth, with tank Identification Number. c. Attach groundwater sampling data, if required based on depth to groundwater. Refer to Closure Site Assessment Guidance for further details regarding requirements for groundwater sampling. d. Is the groundwater more than 5 feet below the bottom of the tank? □ YES □ NO Provide the depth from the ground surface to the groundwater table. Feet: ___________________________ Refer to Closure Site Assessment Guidance for further details regarding requirements for determining groundwater elevation. e. Was there a notable odor found in the bore holes? □ YES □ NO If yes, (1) The odor strength was (mild) (strong) (other) describe: ____________________________________________________________ (2) The odor indicates what type of product: (gasoline) (diesel) (waste oil) (kerosene) (other) describe:___________________________ f. Was free product found in the bore holes? □ YES □ NO If yes, (1) How was free product handled? Describe: ___________________________________________________________________________ (2) What was the measured thickness of free product? __________________________________________________________________ g. Describe the soil type and thickness of all layers encountered in the bore holes and provide boring logs: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ h. Specify the inert solid material used to fill tanks(s): ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 2 of 3 i. Provide the date the tank(s) were filled: ________________________________________________________________________________ j. Were the bore holes properly sealed with bentonite/soil? □ YES □ NO If yes, provide the date: _________________________________________________________________________________________________ 2. DECLARATION I declare that to the best of my knowledge and belief, the statements and information provided are correct and true. I understand that information in addition to that provided above may be needed in order to obtain final approval by the Department of Planning and Natural Resources –Division of Environmental Protection (DPNR-DEP). I understand that tests and procedures that may be required by other departments and agencies to demonstrate adequate site safety or suitability for further development (e.g. soil compaction testing) are in addition to the requirements. I will make contact with an Environmental Specialist (DPNR-DEP) at least two (2) working days to schedule the required inspections. I understand that no work is to commence on the proposed project until a permit has been issued. I understand that site and worker safety are solely the responsibility of the property owner or his agent and that this responsibility is not shared or assumed by the DPNR-DEP. I further understand that a closure must be submitted to the DPNR-DEP within 30 calendar days of completion of UST closure following the guidelines/format prescribed. ____________________________________________________________________________________________________________ SIGNATURE & TITLE: ____________________________________________________________________________________________________________ PRINT NAME: TELEPHONE: ( )______________________________________ DATE_____________________________________________ 3 of 3