Form Un-033 - Closure Application For Aboveground Hazardous Materials Storage Facilities

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CLOSURE APPLICATION FOR ABOVEGROUND
HAZARDOUS MATERIALS STORAGE FACILITIES
For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Please complete and submit this form prior to the closure of any aboveground hazardous materials storage system or facility. Based on
the 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: _______________________________________________________________________________________________
CA
City: ___________________________________________________________ State: ___
_____ Zip: _____________________
(
)
Contact Name: ___________________________________________________ Contact Phone:
________
_________________
Forwarding Address: _________________________________________________________________________________________
(
)
City: _________________________________ State: _____ Zip: ___________ Phone No.:
________
____________________
Property Owner Name: ________________________________________________________________________________________
Property Owner Mailing Address: _______________________________________________________________________________
If different from site address
(
)
City: _________________________________ State: _____ Zip: ___________ Phone No.:
________
____________________
2. Closure Information:
/
/
! Full Facility Closure
! Partial Facility Closure/Remodel
Proposed Date of Closure: _____
_____
_____.
Briefly describe the proposed closure activity. Indicate the previous use(s) of the area(s) intended to be closed and the types of
chemicals used or stored in the area(s) (i.e. by submitting a copy of the Inventory Statements from your Hazardous Materials Business
Plan, etc.). Include equipment, tanks, piping, exhaust and treatment systems, and the proposed final disposition of any hazardous
materials and/or wastes. Attach additional pages if necessary.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Applicant/Agent’s Name (Print): ________________________________________ Title: __________________________________
/
/
Signature of Applicant/Agent: __________________________________________ Date: _____
_____
_____.
Agency Use Only
Application: ! approved
Closure Plan: ! required
Inspection: ! required
! disapproved
! not required
! not required
/
/
$
Fee Received:
____________________
Receipt No.: _______________________ Date: _____
_____
_____.
Comments: _________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
/
/
Staff: ______________________________________________________ Date: ____
____
____.
UN-033
Rev. 05/17/00

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