Bustr Operational Compliance Form – Fill Out and Use This PDF

State of Ohio, Department of Commerce

Division of State Fire Marshal—Bureau of Underground Storage Tank Regulations

P.O. Box 687, Reynoldsburg, Ohio 43068

Phone (614) 752-7938 Fax (614) 752-7942

BUSTR Operational Compliance Form

Ownership of Tanks:	Owner #____________________________________	Location of Tanks:	Facility #___________________________________
_________________________________________________________________		_________________________________________________________________
Owner/Operator Name		Facility Name
_________________________________________________________________		_________________________________________________________________
Address		Address
_________________________________________________________________		_________________________________________________________________
City/State/Postal Code		City/State/Postal Code
_________________________________________________________________		_________________________________________________________________
Owner Contact		County
_________________________________________________________________		_________________________________________________________________
Phone Number		Local Fire Department

Instructions: Starting no later than January 1, 2006, and annually thereafter, rule 1301:7-9-08(G)(1) of the Ohio Administrative Code requires owners and operators of underground storage tanks (UST’s) regulated by the Bureau of Underground Storage Tank Regulations (BUSTR) to perform periodic checks of their UST systems and to attest to their findings below. This form must be completed by the owner and operator or authorized representative and maintained by the owner for at least five years. Please initial and date beside each statement that applies.

Initial:_________ Date:________ I attest that the spill and overfill prevention equipment is in proper working order per Rule 1301:7-9-

08(B) of the Administrative Code.

Initial:_________ Date:________ I attest that the corrosion protection equipment is in proper working order per Rule 1301:7-9-08(C)

of the Administrative Code.

Initial:_________ Date:________ I attest that the UST and piping equipment is in proper working order per Rule 1301:7-9-08(D) of the

Administrative Code.

Initial:_________ Date:________ I attest that the containment and ancillary equipment is in proper working order per Rule 1301:7-9-

08(E) of the Administrative Code.

Initial:_________ Date:________ I attest that the release detection equipment is in proper working order and has been maintained in

accordance with the manufacturers’ requirements per Rule 1301:7-9-08(F) of the Administrative Code.

Initial:_________ Date:________ I attest that any releases of regulated substances identified during the course of completing this form

have been reported to BUSTR in accordance with sections 3737.88 and 3737.882 of the Revised Code.

Please provide an explanation for any of the above statements left incomplete: _______________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

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

_______________________________________ / _________________________________ / _________________

Print name and official title of owner	Signature	Date Signed
(or owner’s authorized representative)
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