Adem Form 279 PDF Details

The Adem 279 form serves as a critical tool in the regulatory oversight of underground storage tanks (USTs) within Alabama, a responsibility taken on by the Alabama Department of Environmental Management (ADEM). This comprehensive notification form is not just a piece of paper but a gateway to ensuring environmental safety and compliance with the state's stringent regulations. It requires detailed information about the ownership, location, and operational details of USTs, emphasizing the importance of clarity and accuracy in its completion. Owners and operators are mandated to disclose the tank's history, construction, substance stored, and the safety measures in place to prevent spills or contamination. Additionally, the form delves into the specifics of the tanks' construction material, corrosion protection mechanisms, and crucially, the methods employed for spill and overfill prevention, alongside release detection techniques. This array of data points underscores the multifaceted nature of managing USTs responsibly. The form not only acts as a notification mechanism for new or existing tanks but also plays a vital role in certifying compliance with the latest installation and financial responsibility regulations, ensuring individuals and entities are held to the highest standards of environmental stewardship.

QuestionAnswer
Form NameAdem Form 279
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesOVERFILL, amazon, Restrictor, AELLD

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ADEM Notification for Underground Storage Tanks

 

Alabama Dept. of Environmental Management

Phone # (334) 270-5655

STATE USE ONLY

 

 

Groundwater Branch/Land Division

Fax # (334) 270-5631

________________ - _______ - _________________NOTIFI

 

 

P. O. Box 301463

E-mail: ustcompliance@adem.state.al.us

 

 

 

 

 

Montgomery, AL 36130-1463

Web Site: adem.alabama.gov

 

 

 

 

INSTRUCTIONS

 

 

Please type or print all items except “signature” in Section XII. This form must be completed for each location containing underground storage tanks. If more than 5 tanks are owned at this location, photocopy, and staple continuation sheets to this form.

Indicate number of continuation sheets attached.

 

 

 

I. OWNERSHIP OF TANK(S)

 

 

II. LOCATION OF TANK(S)

 

 

Owner Name _____________________________________________________________

 

 

Facility I. D. # __ __ __ __ __ __ - __ __ __ - __ __ __ __ __ __

 

 

(Corporation, Individual, Public Agency, or Other Entity)

 

 

(Unless New Location)

 

 

Mailing Address____________________________________________________________

 

 

Facility Name_____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

or Company Site Identifier, as applicable

 

 

City__________________________State_________________________Zip____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street___________________________________________________________________

 

 

Contact__________________________________________________________________

 

 

County Road, Highway, or State Road, as applicable

 

 

Phone #______________________________Fax #_______________________________

 

 

County __________________________________________________________________

 

 

E-mail________________________________

 

 

City__________________________State_________________________Zip____________

 

 

 

 

 

 

 

 

 

 

 

 

(Nearest)

 

 

Type of Owner

 

 

 

 

 

 

 

 

 

 

 

 

State Gov’t

 

 

 

 

Private

 

 

Contact__________________________________________________________________

 

 

 

 

Federal Gov’t

 

 

 

 

Local Gov’t

 

 

Phone #__________________________________

 

 

(GSA Facility I.D. No.___________________________)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. OPERATOR OF TANKS

 

 

IV. FUEL DELIVERY COMPANY

 

 

Operator means any person in control of, or having responsibility for,

 

 

 

 

 

 

 

the daily operation of the UST system.

 

 

 

 

 

Operator Name____________________________________________________________

 

 

Company Name___________________________________________________________

 

 

(If same as section I, mark box here

 

)

 

 

 

 

 

Mailing Address___________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address____________________________________________________________

 

 

City________________________________State__________________Zip____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City________________________________State__________________Zip____________

 

 

Contact__________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact__________________________________________________________________

 

 

Phone #______________________________Fax #_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #__________________________________________________________________

 

 

E-mail___________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. TYPE OF NOTIFICATION

If this is a new notification for this location, mark box here Indicate number of tanks at this location:

If this is an amended or subsequent notification for this location, mark box here Mark box here if tank(s) are located on land within an Indian reservation or on other Indian trust lands:

VII. DESCRIPTION OF UNDERGROUND STORAGE TANKS (Complete for each tank at this location)

(Manifolded tanks and Compartmented tanks are considered one tank)

Tank Identification No.

 

Tank No.

 

Tank No.

Tank No.

Tank No.

Tank No.

Arbitrarily Assigned Sequential Number (e.g. 1u, 2u, 3u)

 

u

 

u

u

u

u

A. Tank Status

 

 

 

 

 

 

 

1.Currently in use

2.Temporarily closed

 

a. Estimated date last used (month/Year)

/

/

/

/

/

B. Tank Location (Mark all that apply)

 

 

 

 

 

1.

Within 300 feet of a private well

 

 

 

 

 

2.

Within 1000 feet of a public water supply well

 

 

 

 

 

3.

Within a Well Head Protection Area

 

 

 

 

 

C. Tank History

1.

Date installed (month/day/year)

/

/

/

/

/

/

/

/

/

/

2.

Date brought into operation by this owner (month/day/year)

/

/

/

/

/

/

/

/

/

/

D. Tank Estimated Total Capacity

1.Number of compartments if compartmented tank

2.Number of manifolded tanks

3.Tank volume (gallons) (manifolded tank capacity is sum of volume of all tanks manifolded together as one tank)

CONTINUE ON NEXT PAGE

ADEM Form # 279 5/14 m2

 

Owner Name

Location

 

 

 

 

 

(from Section I)

(from Section II)

 

 

 

Page No. 2

 

VII.

DESCRIPTION OF UNDERGROUND STORAGE TANKS (Cont’d)

 

 

 

 

Tank Identification No.

Tank No.

Tank No.

Tank No.

Tank No.

Tank No.

 

Arbitrarily Assigned Sequential Number (e.g. 1u, 2u, 3u)

u

u

u

u

u

 

E. Substance Currently Stored (Mark all that apply)

 

 

 

 

 

1.Petroleum

a.Unleaded gasoline

b.Mid-grade gasoline

c.Premium gasoline

d.Diesel

e.Kerosene

f.Aviation fuel (JP-4, etc.)

g.Used oil

h.Virgin oil

i.E-85

j.B-20 Biodiesel

k.Other, please specify

2.Hazardous Substance

a.Please indicate name of principal CERCLA substance or

b.Chemical Abstract Service (CAS) No.

F. Tank Usage (Mark all that apply)

1.Emergency power generator

2.Retail

3.Bulk facility

4.Industrial

5.Local government

6.State/Federal government

7.Farm

8.Heating oil (notification not required)

VIII. CONSTRUCTION AND CORROSION PROTECTION

G. Tank Construction Material (Mark all that apply)

1.Single wall

2.Double wall

3.Steel

4.Fiberglass reinforced plastic

5.Fiberglass coated steel

6.Other, please specify

H. Steel Tank Corrosion Protection (Mark all that apply)

1.Coated & cathodic protection (sti-P3)

2.Field installed cathodic protection

3.Interior lined (e.g., epoxy resins)

4.Other, please specify

I. Pipe Construction Material (Mark all that apply)

1.Single wall

2.Double wall

3.Steel

4.Fiberglass Reinforced Plastic

5.Flexible

6.Other, Please Specify

J. Steel Piping Corrosion Protection (Mark all that apply)

1.Field Installed Cathodic Protection

2.Other, Please Specify

IX. SPILL/OVERFILL PREVENTION

K. Tank Spill Prevention Equipment (Mark all that apply)

1. Catchment Basin

L. Tank Overfill Prevention Equipment (Mark all that apply)

1.Flow Restrictor At 90% Full (e.g., ball float vent valve)

2.Automatic Shutoff Device At 95% Full

3.Audible High Level Alarm At 90% Full

X. RELEASE DETECTION

M. Tank Method of Release Detection (Mark all that apply)

1.Automatic tank gauge

2.Continuous automatic tank gauge

3.Tank tightness testing once every 5 years

4.Interstitial monitoring within secondary containment (e.g., double walled tank)

5.Vapor monitoring

6.Groundwater monitoring

7.Manual tank gauging (only tanks 550 gal. or less)

8.Statistical inventory reconciliation (SIR)

9.Other, Please specify

CONTINUE ON NEXT PAGE

ADEM Form # 279 5/14 m2

 

Owner Name

 

Location

 

 

 

(from Section I)

(from Section II)

 

Page No. 3

 

 

 

X. RELEASE DETECTION (Cont’d)

 

 

 

N. Pressurized Piping Method of Release Detection (At least one item from BOTH

 

 

 

 

 

 

Group I and Group II must be marked)

 

 

 

 

 

 

1.

Group I (Mark one of the following)

 

 

 

 

 

 

 

 

a. Automatic Flow Restrictor (MLLD)

 

 

 

 

 

 

 

 

b. Automatic Shutoff Device (AELLD)

 

 

 

 

 

 

 

 

c. Automatic Shutoff Device (Sump Sensor)

 

 

 

 

 

 

 

d. Other, Please Specify

 

 

 

 

 

 

2.

Group II ( Mark one of the following)

 

 

 

 

 

 

 

 

a. Annual line testing

 

 

 

 

 

 

 

 

b. Automatic electronic line leak detector (AELLD)

 

 

 

 

 

 

 

c. Vapor monitoring

 

 

 

 

 

 

 

 

d. Groundwater monitoring

 

 

 

 

 

 

 

 

e. Statistical inventory reconciliation (SIR)

 

 

 

 

 

 

 

f. Interstitial monitoring within secondary containment (e.g., double

 

 

 

 

 

 

 

walled piping with sump sensor or with monthly inspection)

 

 

 

 

 

 

 

g. Other, Please Specify

 

 

 

 

 

 

 

O. Suction Piping Method of Release Detection ( Mark one of the following)

 

 

 

 

 

1.

Line tightness testing every 3 years

 

 

 

 

 

 

2.

Interstitial monitoring within secondary containment (e.g., double walled

 

 

 

 

 

 

 

piping with sump sensor or with monthly inspection)

 

 

 

 

 

3.

Vapor monitoring

 

 

 

 

 

 

4.

Groundwater monitoring

 

 

 

 

 

 

5.

Only one visible check valve immediately beneath pump and piping slopes

 

 

 

 

 

 

 

towards tank

 

 

 

 

 

 

6.

Statistical inventory reconciliation (SIR)

 

 

 

 

 

 

7.

Other, Please Specify

 

 

 

 

 

 

 

P. Gravity Piping (No leak Detection Required)

 

 

 

 

 

 

 

 

XI. CERTIFICATION OF COMPLIANCE (For Tanks Installed On and After 7/16/12)

 

 

 

Q. UST systems must be installed by an individual certified in accordance with ADEM Administrative Code Rule 335-6-15-.47.

 

 

 

Subparagraph (e) of this rule requires these individuals to:

 

 

1.Exercise supervisory control during installation,

2.Be present at the job site during critical junctures.

R. I have financial responsibility in accordance with Rule 335-6-15.43 and .44. (Mark all that apply)

1.MOTOR FUEL TANKS ONLY Compliance with eligibility requirements of the Alabama Tank Trust Fund AND ONE OF THE FOLLOWING:

a.Net worth of $25,000 OR

b.Insurance, surety bond or guarantee for $5,000 per incident.

2.NON-MOTOR FUEL TANKS ONLY

a.Private Insurance

Insurer and Policy Number:

b. Guarantee or Surety Bond

c.Self-Insurance

S. OATH: I certify that the information concerning installation provided in Items G through P are true to the best of my belie f and knowledge.

Certified Installer Name:

Certification Expiration Date:

Installer Signature:

Signature Date:

Company Name:

Phone Number:

Address:

 

 

XII. CERTIFICATION (Read and sign after completing Sections I. Through XII.)

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.

Name & official title of operator or authorized representative

 

Date Signed

 

 

 

Signature

 

 

 

 

 

Name & official title of owner or authorized representative

Date Signed

Signature

ADEM Form # 279 5/14 m2

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Filling out part 1 in Restrictor

2. Right after this part is done, proceed to enter the applicable details in all these: Operator Name If same as section I, Company Name Mailing Address, If this is a new notification for, If this is an amended or, Indicate number of tanks at this, VII DESCRIPTION OF UNDERGROUND, Manifolded tanks and Compartmented, V TYPE OF NOTIFICATION, a Estimated date last used, Currently in use Temporarily, Tank Identification No Arbitrarily, Within feet of a private well , Tank No, Tank No, and Tank No.

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3. This next segment will be focused on Tank Identification No Arbitrarily, Within feet of a private well , Date installed monthdayyear Date, ADEM Form m, and CONTINUE ON NEXT PAGE - type in all these fields.

Guidelines on how to prepare Restrictor stage 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - Owner Name from Section I, Location from Section II, VII DESCRIPTION OF UNDERGROUND, Page No , Tank No, Tank No, Tank No, Tank No, Tank No, Petroleum, a Unleaded gasoline b Midgrade, Tank Identification No Arbitrarily, Emergency power generator Retail, Hazardous Substance, and k Other please specify - to proceed further in your process!

Restrictor conclusion process described (step 4)

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5. Finally, this last section is precisely what you have to wrap up prior to closing the document. The fields at issue include the following: Tank Identification No Arbitrarily, Emergency power generator Retail, VIII CONSTRUCTION AND CORROSION, G Tank Construction Material Mark, Field Installed Cathodic, Steel Fiberglass Reinforced, and IX SPILLOVERFILL PREVENTION.

The right way to fill in Restrictor step 5

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