Massachusetts Department of Environmental Protection Bureau of Air & Waste UST Facility Name Underground Storage Tank (UST) Program UST6 – System Removal/Closure in Place UST Facility ID #

Important: Check the appropriate action(s) below. Complete ONLY the appropriate section(s) and When filling out submit with the UST1-Cover Sheet/Certification Form. forms on the computer, use UST System Removal/Closure UST System Permanent Closure in Place only the tab key Sections A.1.& B. Sections A.2. & B to move your Removal of Unregistered UST System cursor - do not Permanent Closure of Unregistered UST System use the return Sections A.1., A.3. & B. Sections A.2., A.3. & B key. A. UST System Removal/Closure

1. UST System Removal

Tank ID Tank ID Tank ID Tank ID

Notes: a. Date of tank removal: MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY

• Make additional b. Were all regulated substances copies as needed. removed from the tank managed Yes No Yes No Yes No Yes No per applicable requirements? • If you are Was the tank system rendered replacing a c. Yes No Yes No Yes No Yes No removed tank with inert per 310 CMR 80.47? a new tank in the same location at d. Were all openings secured? Yes No Yes No Yes No Yes No the facility, you must register the e. Was all piping removed? Yes No Yes No Yes No Yes No new tank with MassDEP. f. Capacity of Tank: Gallons Gallons Gallons Gallons • For unregistered tanks, answer the questions in the 2. UST System Permanent Closure in Place appropriate sections. There Tank ID Tank ID Tank ID Tank ID will be no UST Facility Number assigned to tank a. Date of closure in place: MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY systems found at unregistered b. Has a registered professional facilities. civil or structural engineer determined that the tank cannot be removed without endangering the structural integrity of another Yes No Yes No Yes No Yes No UST system, structure, underground piping or underground utilities, per 310 CMR 80.43(3)(a)(1)?

c. Were all regulated substances removed from the tank Yes No Yes No Yes No Yes No managed per applicable requirements? d. Was the tank system rendered Yes No Yes No Yes No Yes No inert per 310 CMR 80.47? e. Was the tank filled with appropriate material (e.g. Yes No Yes No Yes No Yes No concrete slurry mix or approved inert material)?

f. Capacity of Tank: Gallons Gallons Gallons Gallons

UST6 • 5/17 Tank System Removal/Closure in Place • Page 1 of 2 Massachusetts Department of Environmental Protection Bureau of Air & Waste UST Facility Name Underground Storage Tank (UST) Program UST6 – System Removal/Closure in Place UST Facility ID #

A. UST Removal/Closure (continued)

Notes: 3. Removal/Permanent Closure of Unregistered UST System Tank 1 Tank 2 Tank 3 Tank 4 • Make additional copies as needed. If unregistered, where was this tank located? Longitude Longitude Longitude Longitude • Removal/closure of a consumptive Latitude Latitude Latitude Latitude use tank with a capacity of greater than 1,100 B. Assessment of Release at Removal or Closure gallons must comply with the requirements of 310 CMR 80.43 & Tank ID Tank ID Tank ID Tank ID 80.47 Was an assessment conducted in accordance with 310 CMR 80.43(4) within 24 hours of the removal or Yes No Yes No Yes No Yes No before the closure in place was completed?

UST6 • 5/17 Tank System Removal/Closure in Place • Page 2 of 2