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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: _______________________________________________________________________________________________

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

Fee Received:

____________________

Receipt No.: _______________________ Date: _____

_____

_____.

Comments: _________________________________________________________________________________________________

___________________________________________________________________________________________________________

Staff: ______________________________________________________ Date: ____

____

____.

UN-033

Rev. 05/17/00

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

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