Transcription of Petroleum Bulk Storage Application Form
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Petroleum Bulk Storage Application Form
New York State Department of Environmental ConservationDivision of Environmental RemediationPursuant to the Environmental Conservation Law: Article 17, Title 10; and Regulations 6 NYCRR Part 613 and 6 NYCRR Subpart 374-2(Please Type or Print Clearly and Complete All Items for Sections A, B & C) Petroleum bulk Storage ApplicationSection A - Facility/Property Owner/Contact Information PBS Number:TYPE OF Petroleum FACILITY(Check only one)Facility Name:Facility Address (Physical Address, No Boxes):Facility Address (cont.):City: County:Township/City:Facility Operator:Facility Phone Number:Emergency Contact Name:ZIP Code:State:Emergency Telephone Number:Facility (Property) Owner (from Deed):Facility Owner Address (Street and/or Box):City:State:ZIP Code:Owner Telephone Number:Federal Tax ID Number:Type of Owner (check only one):Corporate/Commercial/OtherI hereby certify, under penalty of law, that all of the information provided on this form is true and correct. False statements made herein may be punishable as a criminal offense and/or a civil violation in accordance with applicable state and federal ) Initial/NewFacility2) Change ofOwnership3) TankInstallation,Closing, orRepair4) InformationCorrection5) RenewalFACILITY Name of Owner or Authorized Representative:Signature:Amount Enclosed:Private ResidentState GovernmentLocal GovernmentFederal GovernmentTitle:OWNERDate:$1235NY4 CORRESPONDENCE(Please keep this information up to date.
Petroleum Bulk Storage Application Section C - Tank Ownership Information (for PBS tanks listed in Section B PBS Number: Specific Tanks Owned If tank owner is different from property owner, fill out information below:
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