Application For Residential Abandonment/removal Of Fuel Storage Form
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1APPLICATION FOR RESIDENTIAL ABANDONMENT
/ REMOVAL OF FUEL STORAGE
Community Services
Protective Services C-20
1.
Check one:
Abandonment of storage tank system
Removal of storage tank system
2.
OWNER OF STORAGE TANK SYSTEM
Property Owner’s Name: ___________________________________________________________
Mailing address: __________________________________________________________________
Town/City: ______________________________________ Postal Code: ____________________
Business Phone: ____________________ Fax: ___________________ Home Phone: _________
3.
SITE LOCATION OF STORAGE TANK SYSTEM
Street address: ___________________________________________________________________
Legal address: LOT #: ______ BLOCK: _____ PLAN #: _____________ QUAD/GROUP: _______
4.
WHO OWNS THE PROPERTY WHERE THE STORAGE TANK SYSTEM IS LOCATED:
private land
federal land
territorial land
first nation land
If private land, who is the owner: _____________________________________________________
5.
PROPOSED START DATE: ________________________________________________________
Work cannot commence until application filed with Fire Marshal’s Office
6.
If known, how long has the storage tank(s) been located at this site: _________________________
7.
How long has the storage tank(s) been out of service: ____________________________________
8.
Where is the removed tank(s) going: _________________________________________________
9.
Plans for disposal of tank(s) and/or contaminated soil, if any, must be attached: ________________
10.
Who is conducting the work: ________________________________________________________
I, _______________________________ certify that I am the authorized that the information provided on
this application and any attachments, is correct and enclose the associated fees.
_______________________________
_________________________
______________________
Signature of applicant
Date
# of attachments
This information is being collected under the authority of Section 10 of the Storage Tank Regulations pursuant to the Environment Act.
For further information, contact Protective Services at (867) 667-5217 or 1-800-661-0408 (extension 5217). Fax # 867 667-3165.
YG(5725Q)F1 Rev.09/2010
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