Change Of Ownership Of Ust System(S)

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UST-15
CHANGE OF OWNERSHIP OF UST SYSTEM(S)
FOR TANKS IN
NC
NC DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT / UST SECTION
RETURN
1637 MAIL SERVICE CENTER
COMPLETED
RALEIGH, NC 27699-1637
UST-15 FORM
ATTN: REGISTRATION & PERMITTING
TO:
(919) 733-8486
I. INSTRUCTIONS FOR PREVIOUS UST SYSTEM OWNER
Page 1 must be completed by the previous owner* of the underground storage tank (UST) system(s) and acknowledged by a Notary Public
Please attach copies of proof of ownership transfer (e.g., bill of sale)
If signing as an officer of a corporation, representative of a public agency, administrator of an estate, or as having power of attorney, you must provide a
copy of the legal document that proves you can legally sign in such capacity
Failure to provide supporting documentation will result in no effective change in ownership status
*Pursuant to NCGS 143-215.94A and 15A NCAC 2N .0203, owner means:
…"any person who owns a UST system used for storage, use, or dispensing of regulated substances."
II. PREVIOUS OWNER OF UST SYSTEM(S)
III. LOCATION OF UST SYSTEM(S)
__________________________________________________________
______________________________________________________________
Name of Corporation, Individual, Public Agency, or Other Entity
Facility Name
__________________________________________________________
______________________________________________________________
Street Address
Street Address
_____________________________
__________________________
______________________________
______________________________
City
County
City
County
_____________________________
__________________________
______________________________
______________________________
State
Zip Code
State
Zip Code
(________)___________________
(________)__________________
Telephone Number
Telephone Number
____________________________
Facility ID# (if known)____________________
Federal Tax ID# or Social Security #
________________________________________
__________
Signature
Date
IV. NOTARY ACKNOWLEDGEMENT FOR PREVIOUS OWNER OF UST SYSTEM(S)
_____________________________
_____________________________County
I, __________________________________________________, a Notary Public for said County and State, do hereby certify that
____________________________________________________ personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
Witness my hand and official seal, this the _______ day of _________________________, 20_______.
_____________________________________________________________
Notary Public
(Official Seal)
My Commission Expires: ____________________
UST-15
- 1 -
Revised 11/00

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