UST Forms

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 Corrective ActionPDFWord                           
Document
UST-6124-Hour Release and UST Leak Reporting FormPDF 
UST-6224-Hour Notification of Discharge FormPDF 
 Instructions and Form for Notice of Residual Petroleum (UST Releases) WORD
 Instructions and Form for Notice of Residual Petroleum with Alternate Land Use Restriction (UST Releases) WORD
 Instructions and Form for Notice of Residual Petroleum (AST or other non-UST Releases) WORD
 Instructions and Form for Notice of Contaminated Site WORD
 VPH and EPH Laboratory Reporting Forms WORD
 Soil Permitting  
UST-59Groundwater Quality Monitoring Compliance Report FormPDF 
UST-59ACompliance Report FormPDF 
UST-70Non-Discharge Permit Application for Soil Remediation ProjectsPDFWORD
UST-71Certificate of Approval for Storage/Treatment of Soil Containing Petroleum ProductsPDFWORD
UST-72Agreement for Land Application or Containment and Treatment of Soils Containing Petroleum Products on Private LandsPDFWORD
 Soil Acceptance FormPDF 

 

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 Permits and InspectionRevision DatePDFWord                           
Document
UST-2ASite Investigation Report for Permanent Closure or Change-In-Service - REGISTERED TANKS1/2016PDFWORD
UST-2BSite Investigation Report for Permanent Closure or Change-In-Service - UNREGISTERED TANKS1/2016PDFWORD
UST-3Notice of Intent: UST Permanent Closure or Change-In-Service8/2023PDFWORD
UST-6See next table below for UST-6 Installation Forms   
UST-7ACathodic Protection Testing form for galvanic cathodic protection systems1/2020PDFWORD
Dynamic PDF
UST-7BCathodic Protection Testing form for impressed current cathodic protection systems1/2020PDFWORD
Dynamic PDF
UST-8Notification for Activities Involving Underground Storage Tanks3/2018PDFWORD
UST-12Closure Report Format (see Comprehensive Appendices for Corrective Action Guidelines )6/21/2023 WORD
UST-15Change of Ownership of UST System(s)2/2018PDFWORD
UST-15AOwnership of UST Systems2/2018PDFWORD
UST-16Manual Tank Gauging Record5/2018PDF 
UST-17AUST Suspected Release 24 Hour Notice Form10/2018PDFWORD
UST-17BUST Suspected Release 7 Day Notice Form10/2015PDFWORD
UST-18Application for Tax Certification10/2015PDFWORD
UST-19Certification of Leak Detection Exemption for Suction Piping Associated with USTs3/2018PDFWORD
UST-20Alternative Fuel/Hazardous Substance Compatibility Checklist10/2015PDFWORD
UST-21Impressed Current Cathodic Protection System 60-Day Record of Rectifier Operation1/2020PDFWORD
UST-22AOverfill Prevention Equipment Operability Check (Instructions)11/2022PDFWORD
Dynamic PDF
UST-22BAnnual Leak Detection Equipment Operability Check11/2022PDFWORD
Dynamic PDF
UST-22CAnnual Sump Visual Inspections7/2024PDFWORD
Dynamic PDF
UST-23ATriennial UST Spill Bucket Integrity Testing11/2022PDFWORD
Dynamic PDF
UST-23B

Triennial UST Containment Sump/UDC Integrity Testing

Low-Level Hydrostatic Sump Testing Procedures

5/2020PDFWORD
Dynamic PDF
UST-23CTriennial UST Piping Integrity Testing11/2022PDFWORD
UST-23DTriennial UST Interstice Integrity Testing11/2022PDFWORD
UST-24Certification of No Visible Corrosion on Metallic Piping Components10/2015PDFWORD
UST-27Monthly Walkthrough Inspections11/2022PDFWORD
Dynamic PDF

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 Permits and Inspection - Installation FormsRevision DatePDFWord                           
Document
 Instructions for Completing UST-6 Application to Install or Replace USTs5/2024PDF 
UST-6Application to Install or Replace USTs (Pre/Post-Install)12/2023PDFWORD
Dynamic PDF
UST-6CApplication to Install or Replace USTs (Schedule of Materials)10/2015PDFWORD
UST-6DApplication to Install or Replace USTs (UST Spill Bucket Testing)11/2022PDFWORD
Dynamic PDF
UST-6EApplication to Install or Replace USTs (Tank Installation Testing)11/2022PDFWORD
UST-6FApplication to Install or Replace USTs (Containment Sump/UDC Testing)5/2020PDFWORD
Dynamic PDF
UST-6HApplication to Install or Replace USTs (Post-Installation Piping Integrity Testing)11/2022PDFWORD
UST-6-TOPRUST Post-Installation – Temporary Operating Permit Request1/2024PDFWORD

 

UST Permit ApplicationRevision DatePDF
Compliance Questionnaire3/2020PDF

 

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 Financial ResponsibilityRevision DatePDFWord                           
Document
 Chief Financial Officer Letter11/2005PDF 
UST-FR1Certificate of Insurance (UST-FR1)10/2015PDFWORD
 Certificate of Financial Responsibility10/2015PDF 
 Worksheet for Required Amount of Financial Assurance PDF 

 

Trust FundRevision DatePDFWord                           
Document
State Cleanup Funds
Eligibility Forms                           
IMPORTANT NOTICE FOR NONCOMMERCIAL FUND CLAIMANTS AND CONSULTANTS/CONTRACTORS - Click here
Changes effective 3/1/08 Memo3/2008 WORD
Eligibility Flowchart10/2016PDF 
Memo Eligibility Application Form 01/091/2009 WORD
Eligibility Application Form (rev 5/26/2021)5/2021 WORD
Extra Tank Data Worksheet2/2008 WORD
Extra Corrosion Protection & Spill Overflow worksheet2/2008 WORD
    
Reasonable Rate Documents
98 & 03 Reasonable Rates   
    
Federal Cleanup Funds
Financial Data Request Form1/2004PDF