SOW Attachment 6_951 Tank Farm_STORAGE_TANK_REGISTRATION-PERMITTING_APPLICATION_FORM.pdf

2630-PM-BECB0514 Rev. 6/2019 COMMONWEALTH OF PENNSYLVANIA Form DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS

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STORAGE TANKS REGISTRATION / PERMITTING

APPLICATION FORM

Before completing this form, read the step-by-step instructions provided in this application package.

Facility ID #

Facility Name

DEP USE ONLY

Client ID#

Site ID#

Account #

Auth ID#

APS ID#

Master Auth ID#

I. PURPOSE OF SUBMITTAL

INITIAL (Applies to First-Time Facility Registration)

Register Tanks(s) to be Used* Register Tank(s) to be Temporarily Out of Use

Register Tank(s) to be Removed Register Tank(s) to be Closed in Place

AMENDED (Applies to Currently Registered Tank(s) or Existing Facility)

Changed Owner Information Changed Contact Information

Changed Facility Information Changed Facility Operator Information

Changed to Currently In Use Tank(s)* Added Tank(s) to Existing Facility*

Changed to Temporarily Out of Use Tank(s) Changed to Permanently Closed Tank(s)/Removed

Changed Product Changed to Exempt Tank(s)

CHANGE OF OWNERSHIP

Tanks Changed Ownership and Remain at Same Facility*

* For Underground Storage Tanks (UST), attach the UST Operator Training Documentation Form (2630-PM-BECB0514a) and copies of the Class A and Class B operator training certificates.

II. CURRENT OR NEW TANK OWNER / CLIENT INFORMATION

DEP Client ID# Client Type/Code Fee Kind (check one if applicable)

Volunteer Fire Co/EMS Org State Govt Fed Govt

Organization Name or Registered Fictitious Name Employer ID# (EIN) Dun & Bradstreet ID#

Individual Last Name First Name MI Suffix SSN

Additional Individual Last Name First Name MI Suffix SSN

Mailing Address Line 1 Mailing Address Line 2

Address Last Line – City State ZIP+4 Country

Client Contact Last Name First Name MI Suffix

Client Contact Title Phone Ext

E-mail Address FAX

2630-PM-BECB0514 Rev. 6/2019 Form

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III. SITE INFORMATION

DEP Site ID# Site Name

EPA ID# Estimated Number of Employees to be Present at Site

Description of Site

County Name Municipality City Boro Twp State

County Name Municipality City Boro Twp State

Site Location Line 1 Site Location Line 2

Site Location Last Line – City State ZIP+4

Detailed Written Directions to Site

Site Contact Last Name First Name MI Suffix

Site Contact Title Site Contact Firm

Address Last Line – City State ZIP+4

Phone Ext FAX E-mail Address

NAICS Codes (Two- & Three-Digit Codes – List All That Apply) 6-Digit Code (Optional)

Site to Client Relationship

IIIa. PROPERTY OWNER INFORMATION

Same as Tank Owner Identified in Section II. Different than Tank Owner Identified in Section II; identified below.

Property Owner Contact Last Name First Name MI Suffix

Property Owner Contact Title Phone Ext

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IV. FACILITY INFORMATION

DEP Storage Tank Facility ID# Facility Name Facility Kind

Facility Location Line 1 (if different than Site Location) Facility Location Line 2

Facility Location Last Line - City State ZIP+4

Latitude/Longitude Point of Origin

Latitude Longitude

Degrees Minutes Seconds Degrees Minutes Seconds

Horizontal Accuracy Measure Feet --or-- Meters

Horizontal Reference Datum Code North American Datum of 1927

North American Datum of 1983

World Geodetic System of 1984

Horizontal Collection Method Code

Reference Point Code

Altitude Feet --or-- Meters

Altitude Datum Name The National Geodetic Vertical Datum of 1929

The North American Vertical Datum of 1988 (NAVD88)

Altitude (Vertical) Location Datum Collection Method Code

Geometric Type Code

Data Collection Date

Source Map Scale Number Inch(es) = Feet

--or-- Centimeter(s) = Meters

Flammable & Combustible Liquid Permit # (if applicable)

State or Municipality that Issued the Permit

FACILITY OPERATOR INFORMATION

Same as Owner Identified in Section II. Different than Owner Identified in Section II; identified below.

DEP Client ID# Client Type / Code

Client Contact Last Name First Name MI Suffix

Client Contact Title Phone Ext

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V. CHANGE OF OWNERSHIP INFORMATION

All Tanks Changed Ownership at the Facility

Some Tanks Changed Ownership at the Facility (List all applicable tank numbers in Section VI.)

OWNERSHIP CHANGE TO - Client information is noted in Section II.

OWNERSHIP CHANGE FROM (previous owner information)

Name

Employer ID# (EIN) or SSN

Mailing Address Line 1

Mailing Address Line 2

Address Last Line - City State ZIP+4

Previous Facility ID#

DATE OF SALE/TRANSFER

SIGNATURE & CERTIFICATION OF PREVIOUS OWNER

Previous owner's signature is not available. As required, the "new" owner has attached a deed of transfer or other proof of ownership to this application.

Yes No N/A

I have reviewed this form for submission to the Department. I certify under penalty of law as provided in 18 PA. C.S.A.

§4903 (relating to false swearing) and 18 PA. C.S.A. §4904 (relating to unsworn falsification to authorities), that I have the authority to sign this Section for the transfer of permit or registration for the storage tanks listed herein. Further, I certify that all information provided in Section V is true, accurate and complete to the best of my knowledge and belief.

Type or Print Previous Owner Name

Previous Owner Signature Title Date

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C o n ta m in a ti o n s u s p e c te d o r o b s e rv e d a n d n o ti fi c a ti o n o f c o n ta m in a ti o n f o rm w a s s u b m it te d t o t h e a p p ro p ri a te

D io n a l o ff ic

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D io n a l o ff ic

C lo s u re d o c u m e n t k e p t o n f ile b y o w n r.

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IX. OWNER CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. This registration is conditioned upon compliance with provisions of the Storage Tank and Spill Prevention Act of 1989, all applicable regulations, and with the requirements for obtaining and maintaining a permit required under this Act. I certify my responsibility for assuring the following permit requirements:

• Storage tank systems are in compliance with applicable administrative, technical and operational requirements as specified in Subchapter E for underground tanks or Subchapter F or G for aboveground tanks.

• Tank handling and inspection activities are performed by an individual possessing DEP certification in the appropriate category as required in Subchapters A and B.

• Underground storage tanks meet the applicable financial responsibility requirements of Subchapter H (relating to financial responsibility requirements).

• A Spill Prevention Response (SPR) Plan must be submitted to the appropriate DEP regional office for facilities that have aboveground storage tanks where the total capacity of all aboveground tanks is greater than 21,000 gallons.

• Other state and local permits required for operation of the tank system have been attained.

My signature represents to the Department that I own the storage tank(s) and am aware of the responsibilities and potential liabilities as an “owner” arising under the Storage Tank and Spill Prevention Act of 1989 and all applicable regulations. I am also advised that statements made on this registration is made subject to the penalties of 18 PA. C.S.A.

Section 4904 relating to unsworn falsification to authorities.

Type or Print Owner Name

Owner Signature Title Date

Information & Invoices should be sent to:

Tank Owner Contact

Site Contact

Facility Operator

Other Responsible Party Identified Below

Contact Title Phone Ext.

E-mail Address

Client to Site (Facility) Relationship

-P

M -B

E C

B v /2

I N

S T

A L

L E

R

R E

M O

V E

R C

E R

T

IF

IC

A

T is s e c ti o n m u s t b e c o m p le te d b y t h e c e rt if ie d t a n k h a n d le r( s w h o i s r e s p o n s ib le f o r th e i n s ta lla ti o n o r re m o v a l fr o m s e rv ic e o f th e a b o v e g ro u n d a n d u n d e rg ro u n d s to ra g e t a s te m s l is te d i n

S e c ti o n n k m o d if ic a ti o n a c ti v it y m u s t b e s u b m it te d o n a

T a n k M o d if ic a ti o n R e p o rt fo rm

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A s t h e c e rt if ie d t a n k h a n d le r re s p o n s ib le f o r th e t a n k h a n d lin g a c ti v it ie s i n t h e c a te g o ry o r c a te g o ri e s l is te d

I c e rt if y t h a t a ll ta n k h a n d lin g a c ti v it ie s w e re c o n d u c te d i n c o m p lia n c e w th d e s ig n in s ta lla ti o n a n d o p e ra ti o n s ta n d a rd s o f th e S to ra g e

T a n k a n d

S p ill P re v e n ti o n A c t o f a n d a ll a p p lic a b le r e g u la ti o n s

I a ls o c e rt if y u n d e r p e n a lt y o f la w a s p ro v id e d

P A

C .S

.A re la ti n g t o u n s w o rn f a ls if ic a ti o n t o a u th o ri ti e s t h a t th e i n fo rm a ti o n p ro v id e d t h e re in i s t ru e a c c u ra te a n d c o m p le te t o t h e b e s t o f m y k n o w le d g e a n d b e lie f.

n ta ll e r/ R e m o v e r N a n s tr u c ti n d rd iv id u a l C e rt if ic a ti o rt if ic a ti te g m p a rt if ic a ti o ta ll e r/ R e m o v e r S ig n a

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I c e rt if y t h a t th e t a n k (s lis te d b e lo w a re c o n s tr u c te d t o a p p ro p ri u s tr y s ta n d a rd s a n d if a p p lic a b le to m a n u fa c tu re r’ s s p e c if ic a ti o n s th a t th e t a n k (s h a v e b e e n t e s te d a s r e q u ir e d b y i n d u s tr y s ta n d a rd s a n d t h a t th e t a n k (s m e e t o r e x c e p lic a b le d e s ig n a n d o p e ra ti n g s ta n d a rd s a n d a re i n c o m p lia n c e w it h t h e r e q u ir e m e n ts o f th e

S to ra g e

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I a ls rt if y u n d e r p e n a lt y o f la w a s p ro v id e d i n

P A

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.A re la ti n g t o u n s w o rn f a ls if ic a ti o n t o a u th o ri ti e s t h a t th e i n fo rm a ti o n p ro v id e d h e re in i s t ru e a c c u ra te a n d c o m p le te th b e s t o f m y k n o w le d g e a n d b e lie f.

n p e c to r N a n s tr u c ti n d rd iv id u a l C e rt if ic a ti o rt if ic a ti te g m p a rt if ic a ti o p e c to r S ig n a

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S it e -S p e c if ic I n s ta ll a ti o n P e n n n n n n n n n n