Closure Application for Aboveground HazMat Srtorage …

1 UN-033 05/17/00 Closure Application FOR ABOVEGROUNDHAZARDOUS MATERIALS STORAGE FACILITIESFor Use by Unidocs Member Agencies or where approved by your Local JurisdictionPlease complete and submit this form prior to the Closure of any Aboveground hazardous materials storage system or facility. Based onthe information submitted below, and the complexity of the Closure , a written Closure Plan may be required (see guidelines).1. Facility Information: (Note: Print or type all information.)Facility Name: _____Facility Phone:(_____)_____Site Address: _____City: _____State: ___CA_____ Zip: _____Contact Name: _____Contact Phone:(_____)_____Forwarding Address: _____City: _____State: _____ Zip: _____ Phone No.:(_____)_____Property Owner Name: _____Property Owner Mailing Address: _____ If different from site addressCity: _____State: _____ Zip: _____ Phone No.

2 :(_____)_____2. Closure Information: ! Full Facility Closure ! Partial Facility Closure /RemodelProposed Date of Closure : _____/_____ describe the proposed Closure activity. Indicate the previous use(s) of the area(s) intended to be closed and the types ofchemicals used or stored in the area(s) ( by submitting a copy of the Inventory Statements from your hazardous Materials BusinessPlan, etc.). Include equipment, tanks, piping, exhaust and treatment systems, and the proposed final disposition of any hazardousmaterials and/or wastes. Attach additional pages if s Name (Print): _____ Title: _____Signature of Applicant/Agent: _____Date: _____/_____ Use OnlyApplication:! approved! disapprovedClosure Plan:! required! not requiredInspection:! required! not requiredFee Received:$ _____Receipt No.: _____ Date: _____/_____ : _____Staff: _____ Date: ____/____/____.