Download Contaminated Soil Permits UST-71 UST-71

Contaminated Soil Permits
UST-71
North Carolina Division of Waste Management
UST-71
Certificate of Approval for Storage/Treatment of Soil Containing Petroleum Products
Certificate #__________________
Of 50 Cubic Yards or Less
Temporary Storage
Other (explain below)
Approval is Hereby Granted To:
Name:____________________________________ Phone Number:_____________
Address: ____________________________________________________________
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for the storage/treatment of approximately ________ cubic yards of contaminated soil as specified below:
Type of Contaminants: ____________________________________________________________________________
Location of Source of Contaminant(s) (including business/owner name): ______________________________________
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Address of Source of Contaminant: ___________________________________________________________________
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County: ____________________________
Method of Storage/Treatment: _______________________________________________________________________
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Location(s) where contaminated soil will be stored or applied of (map(s) must be provided): ______________________
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This approval is based upon information provided to the Regional Supervisor, __________________ Regional Office, by
the responsible party, who hereby agrees to conduct the approved soil management activities in accordance with
applicable state, local or federal requirements and additionally agrees to abide by any special conditions or limitations
specified below and on the second page of this form. (NOTE: If the contaminated soil to be managed is regulated
under Subtitles C or D of RCRA, then the soil shall not be stored or treated without written permission from the
NC Division of Waste Management.)
Special Conditions, Limitations or Comments: __________________________________________________________
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Certificate of Approval issued this the __________ day of __________________, 20___.
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Signature of DWM Representative
Signature of Responsible Party
___________________________ Regional Office
UST-71 (07/03)
September 1, 2003
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Contaminated Soil Permits
UST-71
UST-71
Certificate of Approval for Storage/Treatment of Soil Containing Petroleum Products
Special Conditions, Limitations or Comments (continued):
Soil Quarantine requirements 15A NCAC 2H .0217(f)
Land Use Agreement as described in 15A NCAC 2H .0205(d)(12)(a)(vii)
Performance Standards 15A NCAC 2H .0217(f)
Buffer Requirements (NCAC 15A 2H .0219(j)):
a) 100 feet from any habitable residence or place of public assembly under separate ownership or which is to
be sold;
b)100 feet between the application area and any public or private water supply, including wells;
c) 100 feet between application area and waters classified as WS-II, WS-III, or B;
d)100 feet between the application area and the normal high water levels of waters classified as SA or SB;
e) 100 feet between application area and any stream, lake, river or natural drainage way;
f) 50 feet between application area and property lines;
g)10 feet between application area and surface water interceptor drains or diversions (up slope);
h)25 feet between application area and any surface water interceptor drains or diversions (down slope) and any
groundwater drainage systems; and
i) 10 feet of area shall be maintained around the application area with a permanent vegetative cover to be
included within any of the existing buffers where applicable.
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UST-71 (07/03)
September 1, 2003
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