DEPARTMENT OF PLANNING AND NATURAL RESOURCES
DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION 45 Mars Hill Cyril E. King Airport Frederiksted Terminal Building, 2nd Floor St. Croix, VI 00840 St. Thomas, VI 00802 (340) 773-1082 (340) 774-3320 APPLICATION FOR PERMIT TO USE/OPERATE UST SYSTEM TYPE OF ACTION □ 1. NEW PERMIT □ 2. RENEWAL PERMIT (Check one item only) □ $500 APPLICATION FEE PAID (Account NO: RV 4421) 400 I. FACILITY / SITE INFORMATION BUSINESS NAME FACILITY ID# (For Office Use) LOCATION OF TANK (Address) 401 FACILITY OWNER TYPE 402 □ 1. CORPORATION □ 4. LOCAL/PUBLIC AGENCY* □ 2. INDIVIDUAL □ 5. OTHER __________________ □ 3. PARTNERSHIP * If owner of UST is a public agency: name of supervisor of division, section or office which operates the UST (This is the contact person for the tank records) 406 BUSINESS □ 1. GAS STATION □ 2. COMMERCIAL TYPE □ 3. OTHER _______________________ 403 TOTAL NUMBER OF TANKS 404 Is facility on Government Property? □ YES □ NO 405 FACILITY INFORMATION □ 1. EPA-FORM 7530-1 (9-98) ATTACHED □ 3. PARCEL ID No:______________________________________________ □ 2. …
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DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION 45 Mars Hill Cyril E. King Airport Frederiksted Terminal Building, 2nd Floor St. Croix, VI 00840 St. Thomas, VI 00802 (340) 773-1082 (340) 774-3320 APPLICATION FOR PERMIT TO USE/OPERATE UST SYSTEM TYPE OF ACTION □ 1. NEW PERMIT □ 2. RENEWAL PERMIT (Check one item only) □ $500 APPLICATION FEE PAID (Account NO: RV 4421) 400 I. FACILITY / SITE INFORMATION BUSINESS NAME FACILITY ID# (For Office Use) LOCATION OF TANK (Address) 401 FACILITY OWNER TYPE 402 □ 1. CORPORATION □ 4. LOCAL/PUBLIC AGENCY* □ 2. INDIVIDUAL □ 5. OTHER __________________ □ 3. PARTNERSHIP * If owner of UST is a public agency: name of supervisor of division, section or office which operates the UST (This is the contact person for the tank records) 406 BUSINESS □ 1. GAS STATION □ 2. COMMERCIAL TYPE □ 3. OTHER _______________________ 403 TOTAL NUMBER OF TANKS 404 Is facility on Government Property? □ YES □ NO 405 FACILITY INFORMATION □ 1. EPA-FORM 7530-1 (9-98) ATTACHED □ 3. PARCEL ID No:______________________________________________ □ 2. SITE PLAN ATTACHED □ 4. FILED UST @ RECORDER OF DEEDS II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING ADDRESS 409 CITY 410 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE □ 1. CORPORATION □ 3. PARTNERSHIP □ 5. OTHER 413 □ 2. INDIVIDUAL □4. LOCAL AGENCY III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE □ 1. CORPORATION □ 4. LOCAL AGENCY □ 2. INDIVIDUAL □ 5. OTHER ________________________ □ 3. PARTNERSHIP 420 IV. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) □ 1. SELF-INSURED □ 3. INSURANCE □ 5. EXEMPTION 422 □ 2. GUARANTEE □ 4. LETTER OF CREDIT □ 6. OTHER ________________________ V. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notification and mailing. 423 Legal notification and mailings will be sent to the tank owner unless box 1 or 2 is checked. □ 1. FACILITY □ 2. PROPERTY OWNER □ 3. TANK OWNER VI. APPLICANT SIGNATURE Certification – I certify that the information provided is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT (Print) 426 TITLE OF APPLICANT 428 1998 UPGRADE NUMBER (For Local Use Only) 429 ( ) APPROVED ( ) DISSAPPROVED Certificate MAILED _____________ DELIVERED _______________ DPNR-UST– FORM A (10/03)