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3. 
   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. 2930 Wetmore Avenue Everett WA 98201- 7th Floor

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

    www.everettfire.org

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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

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