MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
Remediation Division
INTENT OF REMOVAL, CLOSURE OR CHANGE-IN-SERVICE OF UNDERGROUND STORAGE TANKS
This information is required pursuant to Part 211, Underground Storage Tank Regulations, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended. An owner/operator who fails to notify is subject to a misdemeanor and/or civil penalties, not to exceed $5,000 per day for each tank.
INSTRUCTIONS: NOTICES WILL ONLY BE ACCEPTED ON THIS FORM. YOUR UST MUST BE REGISTERED PRIOR TO SUBMITTAL OF THIS FORM. ALL information must be completed. See below for additional information. If you have questions, call 517-335-7279, Monday through Friday between 8:00 am - 5:00 pm.
All fields marked with a (!) are required. You will not be able to submit the form without completing them. 
I. OWNERSHIP OF TANKS
Please check if new owner's address.
  (!)Name 
(!)Company
(!)Street Address
Street Address
(cont.)
(!)City
(!)State
(!)Zip
(!)County
(!)Area Code & Phone Number
II. LOCATION OF TANKS
Please check if same as Section I.
(If checked, fields in this section marked with a (*) are optional.)
(!)(*)Contact Person for Location
(!)Facility Number
(see invoice)
(!)Facility Name
(or Company Site Identifier)
(!)(*)Street Address
(P.O. Box not acceptable)
Street Address (cont.)
(!)(*)City
(!)(*)State
(!)(*)ZIP
(!)(*)County
(!)(*)Area Code & Phone Number
III. TANK INFORMATION
(!)Tank Number   (!)Product Last Stored In Tank   (!)Size of Tank   (!)Indicate action to be taken
(as indicated on UST Invoice) (gallons) Removal, Change in Service, Close in Place
IV. Comments
V. Submitter Information
(!)Name
CAPTCHA (!) Anti-Spam Code: Write the characters in the image:
(!)Company
(!)Area Code & Phone Number
(!)email Address

TEST THIS IS NOT A REGISTRATION FORM. AN AMENDED REGISTRATION FORM, EQP3821, MUST BE FILED TO REMOVE THE LISTED TANKS FROM THE BILLING CYCLE.

INSTRUCTIONS

REPORTING REQUIREMENTS

This form must be received by the Remediation Division (RD) 30 days prior to the commencement of work indicated.

An underground storage tank (UST) subject to Part 211, Underground Storage Tank Regulations, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended, must be registered by the current owner and have all fees paid to be considered registered with the RD. The UST owner/operator or agent must complete this form as instructed. The copies returned by the RD will indicate the earliest closure date along with the last date this form is valid.

A site assessment shall be conducted during the closure/change-in-service, with results sent to the RD along with the form provided. The owner/operator must also submit an amended registration form notifying the RD of completion of closure/change-in-service within 30 days after the date of the closure/change-in-service.

INSURANCE REQUIREMENTS

Pursuant to Section 21107 of Part 211, a person who removes USTs shall maintain pollution liability insurance of not less than $1,000,000 per occurrence.

CONFIRMED RELEASE

A confirmed release must be reported to the RD within 24 hours. A confirmed release waives the requirements of submitting this form, waiting 30 days, and conducting a site assessment. Once reported, the owner/operator will be informed regarding rules for further testing and cleanup activities. Releases may be reported by fax to 517-335-2245, by submitting this web form, or by mail to: Storage Tank Unit, Remediation Division, PO Box 30241, Lansing, MI 48909-7657.

CLOSURE OF TANKS

Tanks shall be emptied of all liquid and accumulated sludge and purged of all vapors. Piping shall be emptied of all liquid and sludge, purged and capped, or removed from the ground. Permanent closure requires removal of the UST from the ground, unless it can be documented that removal of the UST would cause damage to a permanent structure. The tank can be closed-in-place after the 30 day waiting period provided that the required documentation is placed in the owner’s file. If closure in place is necessary, the tank must be emptied of liquid, sludge and vapors and filled 100% with inert solid material (sand, fly-ash concrete or pea gravel). Piping shall be closed as indicated above. A site assessment is still required if tanks are closed-in-place.

CHANGE-IN-SERVICE

A change-in-service is defined as going from the storage of a regulated substance to an unregulated substance. The tank must be cleaned and purged as stated above, and a site assessment must be performed prior to the introduction of the unregulated substance.

NOTIFICATION

Per R 29.2153(d) of the Administrative Rules promulgated under Part 211 of Act 451, the owner/operator shall notify the Hazardous Materials Storage Inspector at the RD district office not less than two working days prior to the work being performed.

If you have questions regarding the above instructions, please contact the RD at 517-335-7279, Monday through Friday between 8:00 am - 5:00 pm.

EQP 3824 (06/2002)