Hazardous Substance Bulk Storage Application Return ...
99=Other (Specify):New York State Department of Environmental ConservationDivision of Environmental Remediation(See instructions and please be sure to complete Sections A & B) Hazardous Substance bulk Storage ApplicationPursuant to the Hazardous Substance bulk Storage Law, Article 40 of ECL and 6 NYCRR 596-599Section A - Facility/Property Owner/Contact InformationCBS Number:TYPE OF CHEMICAL Storage FACILITY(Check only one)Facility Name:Facility Address (Physical Address, No Boxes):Facility Address (cont.):City: County:Township or City:Facility Operator:Facility Phone Number:Emergency Contact Name:ZIP State:Emergency Telephone Number:Facility (Property) Owner (from Deed):Facility Owner Address (Street and/or Boxes):City:State:ZIP Code:Owner Telephone Number:Federal Tax ID Number:Type of Owner (check only one):Corporate/Commercial/OtherTransacti on1) Initial/NewFacility2) Change ofOwnership3) TankInstallation,Closing, orRepair4) InformationCorrection5) RenewalFACILITY Name of Property Owner or Authorized Representative:Signature:Amount Enclosed:01= Storage Terminal/Petrol.
Action Tank Number (1) (2) Tank Location (3) Status (4) Installation, Out-of-service Or Permanent Closure Date (mm/dd/yyyy) Application will be returned if
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