DISTRICT OF COLUMBIA
DISTRICT OF COLUMBIA
DISTRICT DEPARTMENT OF THE ENVIRONMENT
UST/LUST ACTIVITY NOTIFICATION
PLEASE FILL OUT THIS FORM (AS APPLICABLE)
AND RETURN TO THE UNDERGROUND STORAGE TANK BRANCH, DDOE
DATE:
NOTE: UNLESS WRITTEN NOTIFICATION HAS PREVIOUSLY BEEN SUBMITTED, THE ABOVE DATE MUST, BY REGULATION, BE AT LEAST 2 WEEKS PRIOR TO THE ACTUAL DATE OF THE ACTIVITY INDICATED ON ITEM #3C & #4C.
1) Name of Establishment: Facility ID (if known):
Site Address:
Contact Person: Phone #: Email:
2) Contractor/Consultant Name:
Address:
Contact Person: Phone #: Email:
3) UST ACTIVITY: Attach A Site Plan.
NOTE: FOR INSTALLATION/UPGRADE COMPLETE UST INSTALLATION/UPGRADE CHECKLIST
A) Install: Remove: Abandon: Repair: Test:
B) Tank Tightness Test (Method):
C) Estimated Date To:
Install Remove Abandon Repair Test
D) Total # Of USTs To Be:
Installed: Removed: Abandoned: Repaired: Tested:
E) UST Contents (Check, If Known): Heating Oil (Grade): Diesel Oil:
Used Oil: Gasoline (Type): Other (Specify):
4) LUST ACTIVITY: LUST # _____________________(if known)
A) Boring/Well Installation (#): /
B) Install CAP System (Type):
C) Estimated Date To: Drill Borings/Wells: / Install CAP System:
5) Short Description of the Activity - Attach A Site Plan.
Filers Name (Please Print) Signature Date
Rev. 04/19/2013 1200 First Street NE, 5th floor, Washington DC 20002, Tel: 202-535-2600, Fax: 202-535-1383, Email: ust.ddoe@, Website: green.
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