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Residential Tank Decommissioning Report

2. 

3. <p><span style="font-size: small; color: #000000;"><strong><br>This report is required to be completed by the current holder of an ICC UST Decommissioning Certificate who conducted or&nbsp;directly supervised the decommissioning work.</strong></span></p>

   
   This report is required to be completed by the current holder of an ICC UST Decommissioning Certificate who conducted or directly supervised the decommissioning work.

5. Permit Number:*

7. Company Name:*

8. Decommissioner’s Name*

10. Decommissioner’s Mailing Address

12. City

13. State

14. Zip

16. ICC Underground Storage Tank Decommissioning Certification number:

18. Property Owners Name:

20. Address of Property Where Tank is located*

22. City

23. State

24. Zip

26. Approximate Size of the Tank or Dimensions:

27. Approximate Age of Tank:

29. Date of Decommissioning:
    Date of Decommissioning:

30. Last Known Contents of the Tank:

32. Upload Project plans or documents relating to tank

33. Date of Pump and Rinse:
    Date of Pump and Rinse:

35. Type of Decommissioning:

    1. Removal
    2. Abandonment in Place
    3. Removed and Replaced with a New Tank
37. Disposal Location:

39. If Abandoned, Specify Type of Inert Fill Material:

    1. Concrete Slurry
    2. Sand

    1. Other Inert Material (specify)
    2. Foam

40. Specify:

42. Soil Contamination Observed:

44. Recommendation:

46. Acknowlegement*

    In pressing the submit button, you agree that the information provided is accurate. Submission is in lieu of a signature.

    1. I agree
48. <p style="text-align: center;"><span style="color: #000000;"><strong>2930 Wetmore Avenue Everett WA 98201- 7th Floor</strong></span></p> <p style="text-align: center;"><span style="color: #000000;"><strong>PH. (425) 257-8120 FAX (425) 257-8139 </strong></span></p> <p style="text-align: center;"><span style="color: #000000;"><strong>www.everettfire.org</strong></span></p>

    2930 Wetmore Avenue Everett WA 98201- 7th Floor

    PH. (425) 257-8120 FAX (425) 257-8139

    www.everettfire.org

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50. Email address

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