USVI Public Records

Document text

Application For Terminal Facility License Part I: Application Type Enter a check in the appropriate box identifying application type. This application is for (check one): A new license A renewal of an existing license A modification of an existing license If other than new, provide existing license number: Part II: License Fee Information Each registrant shall obtain from DPNR DEP a license for each of its terminal facilities in the territory and shall pay an amount; not to exceed five hundred ($500) dollars, determined by DEP upon the basis of the total capacity of the terminal facility. In addition a two hundred and fifty ($250) dollars permit processing fee. DEP will not process an application unless the required fee has been paid. Part III: Applicant Information 1. Fill in the name of the applicant(s) as indicated on the Permit Application Transmittal Form Applicant: ____________________________________________________________________ Phone:_________________________ ext.: ____________ Fax: ________________________ Enter a check mark if there are co-applicants. If so, label and attach additional sheet(s) with the required information as supplied above. 2. List primary contact for departmental correspondence and inquires, if different. Name: ________________________________________________________________ Mailing Address: _______________________________________________________ City: _______________________________State: ___________________Zip Code: ________________ Business Phone: _____________________ext: _________________Fax:_________________ Contact Person: ___________________________________Title: _____________________________ DEP USE ONLY Rec’d by Date STT/J ____ STX_____ Application No._______ Please complete this form in the accordance with the instructions to ensure the proper handling of your application. Print or type unless otherwise noted. You must submit the application fee along with this form. Part III: Application Information (cont.) 3. List attorney or representative, if applicable: Firm Name: _____________________________________________________________ Mailing Address: _________________________________________________________ City: ______________________________State: __________ Zip Code: __________ Business Phone: _____________________ext.____________ Fax: ______________ Attorney Name: ______________________________ Title: _____________ 4. List the owner(s) of the facility to be licensed. Please enter a check mark, if additional sheets are attached. Name: __________________________________________________________________ Mailing Address: _________________________________________________________ City: ____________________________ State: _____________ Zip Code: __________ Business Phone:_______________________ ext._______________ Fax: _______________ Contact Person: _________________________________________ Title: _______________ 5. Identify the operator and alternate operator of the terminal. Operator Name: _________________________________________________________ Mailing Address: ________________________________________________________ City: ___________________________State: ________________ Zip Code: __________ Business Phone:___________________ ext._________________ Fax:_______________ Alternate Operator Name: ___________________________________________________ Mailing Address: __________________________________________________________ City: ___________________________ State: ______________ Zip Code: _________ Business Phone:___________________ ext.________________ Fax:_______________ 6. Identify the terminal manger, if different than the terminal operator. Name: ___________________________________________________________________ Mailing Address: __________________________________________________________ City: ____________________________ State: ________________ Zip Code: __________ Business Phone:___________________ ext._____________ Fax:_______________ Title (if different): __________________________________________________________ Part III: Applicant Information (cont.) 7. Identify the Qualified Individual and Alternate Qualified Individual of the terminal (if different than Operator and Alternate Operator list in letter E). Qualified Individual Name: _____________________________________________________ Mailing Address: _____________________________________________________________ City: _____________________________ State: _________________Zip Code: ___________ Business Phone:____________________ ext._________ Fax:_________________ Alternate Qualified Individual Name: ______________________________________________ Mailing Address: ______________________________________________________________ City: ______________________________State: ___________ Zip Code: _____________ Business Phone:_____________________ ext._____________ Fax: __________________ 8. List any other engineer(s) or consultant(s) employed or retained to assist in preparing the application or in designing and consulting the facility. Please enter a check mark if additional sheets are attached. Name: ______________________________________________________________________ Mailing Address: _____________________________________________________________ City: ___________________________ State: ___________ Zip Code: _____________ Business Phone:___________________ ext._____________ Fax:__________________ Contact Person: _____________________________________ Title: _________________ Service Provided: _____________________________________________________________ 9. Identify cleanup any organization(s) to which the owner or operator of the facility belongs to. Name: ______________________________________________________________________ Mailing Address: _____________________________________________________________ City: ___________________________ State: ___________ Zip Code: _____________ Business Phone:___________________ ext._____________ Fax:__________________ Contact Person: _____________________________________ Title: _________________ Service Provided: _____________________________________________________________ Part IV. Site Information A. Name of Facility, if applicable: _______________________________________________________ Street address or Description of Location: _______________________________________________ City: _________________________________State: __________________Zip Code: _____________ Latitude and longitude of the exact location of the point where product enters the terminal in degrees, minutes, and seconds. Latitude: __________________________________ Longitude: ______________________________ Method of determination (check one): GPS USGS Map Other (please specify): If a USGS Map was used, provide the quadrangle name: Part V. Supporting Documents Please enter a check mark by the attachment as verification that all attachments have been submitted with this license application form. When submitting any supporting documents, please label the documents as indicated in this part(e.g., Attachment A, etc.) and be sure to include the applicant’s name as indicated. Attachment A: Applicant Compliance Information Form Attachment B: Copy of any field survey conducted to identify the presence of any endangered, threatened or special concern species. Attachment C: Spill Prevention Control and Countermeasure (SPCC) Plan Attachment D: Detailed Site Plan Attachment E: Facility Inspection Attachment F: Facility Response Plan(s) Attachment G: Spill Containment and Removal Equipment Listing Attachment H: Terminal Operation Manual Attachment I: Terminal Facilities required filing bond Part VI. Applicant Certification The applicant and the individual(s) responsible for actually preparing the application must sign this part. An application will be considered incomplete unless all required signatures are provided. “I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on responsible investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief. I certify that this application is on complete and accurate forms as prescribe by the Commissioner without alteration of the text.” / / Signature of Applicant Date Name of Applicant (print or type) Title (if applicable) / / Signature of Preparer Date Name of Preparer (print or type) Title (if applicable) Note: Please submit the Application Form, Fee and all supporting Documents to: Department of Planning & Natural Recourses Division Of Environmental Protection Cyril E. King Airport 45 Mars Hill Terminal Building, Second Floor Fredriksted, St. Croix, U.S. VI 00840 St. Thomas, U.S. VI 00802 (340) 773-1082 (340) 774-3320