Date Su
b
(
Check
al
Inst
a
Und
Business
Address:
City:
Locatio
n
T
Contrac
t
A
ddress:
City:
Contact
I
Contact
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Schedul
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Complet
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this appl
i
1.
C
N
2.
N
3.
U
4.
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5.
A
Failure
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A
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l applicabl
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Name:
n
of Tank(s):
T
ANK ID#
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or:
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umber of t
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site plan i
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y
Permi
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sure Intent.
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entifying an
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t
Applic
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b
ove Gr
o
n
ing & Inspectio
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rest, NC 27587
/
v
al
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ANK
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on and prov
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to include: i
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nd storage
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e implied dis
p
y
significant e
l
bo
ve listed it
e
a
tion for
d
onmen
t
o
und St
o
ns Department
| Phone: (919) 4
3
T
estin
g
v
e Ground T
a
t
ate:
CAPACIT
Y
i
de all requir
e
n
stallation, e
x
t
anks.
T
he f
o
of Environ
m
d
ing the capa
c
p
osition of t
h
l
ements of t
h
e
ms will res
u
the Inst
t
of Und
e
o
rage Ta
| 301 South Bro
o
3
5-9530 | Fax: (
9
g
a
nk
Contact:
Phone:
Y
Contractor’
Phone:
State:
Title:
Mobile No.
e
d informati
o
x
cavation, re
m
o
llowing ite
m
m
ent, Health
c
ity and cont
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h
e tanks post
-
h
e tank remo
v
u
lt in delay
o
t
allation,
e
rgroun
d
nks
o
ks Street
9
19) 435-9538
F
Chang
e
Piping Syst
e
T
AN
K
s N.C. ID#:
:
o
n at least fo
u
m
oval, testin
g
m
s are
requi
re
and Natural
e
nts of each
t
-
removal.
v
al/abandon
m
o
r refusal to
Date:
Date:
d
or
F
ee: $100.00
(
e
-in-Service
e
m
Zip:
K
CONTE
N

Zip:
u
rteen (14) d
a
g
, closure or
red
to be sub
m
Resources
G
t
ank.
m
ent site.
issue this p
e
(
per tank)
N
TS
a
ys prior to
r
change-in-
m
itted with
G
W/NST-3
e
rmi
t
.
click to sign
signature
click to edit
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