Get 2570 Fm Bwm0607

2570-FM-BWM0607 Form 6/2009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT STORAGE TANK REGISTRATION AMENDMENT FORM Before completing this form read the instructions provided for this form. I. FACILITY AND CLIENT INFORMATION Facility ID Facility Name County Municipality Client s Name or Registered Fictitious Name Client ID II. PURPOSE OF SUBMITTAL Change to C status Currently In Use Tank s Change Capacity Change Substance Change Contact Information Tank Change Date Mo/Day/Yr Status III. TANK INFORMATION Capacity Gallons Substance Name CAS Component IV. CONTACT INFORMATION FOR Facility Owner Responsible Official Facility Operator Is person below to receive the invoice and registration certificate YES Last Name First Name MI Phone E-mail Company Name Mailing Address City State ZIP Property Owner NO Suffix V. OWNER SIGNATURE My signature represents to the Department that I own or represent the owner of the storage tank s and am aware of the responsibilities and potential liabilities as an owner arising under the Storage Tank and Spill Prevention Act of 1989 and all applicable regulations. I am also advised that statements made on this form are made subject to the penalties of 18 PA. C. S*A. Section 4904 relating to unsworn falsification to authorities. Type or Print Owner Name Owner Signature Owner s Representative Date. FACILITY AND CLIENT INFORMATION Facility ID Facility Name County Municipality Client s Name or Registered Fictitious Name Client ID II. PURPOSE OF SUBMITTAL Change to C status Currently In Use Tank s Change Capacity Change Substance Change Contact Information Tank Change Date Mo/Day/Yr Status III. PURPOSE OF SUBMITTAL Change to C status Currently In Use Tank s Change Capacity Change Substance Change Contact Information Tank Change Date Mo/Day/Yr Status III. TANK INFORMATION Capacity Gallons Substance Name CAS Component IV. CONTACT INFORMATION FOR Facility Owner Responsible Official Facility Operator Is person below to receive the invoice and registration certificate YES Last Name First Name MI Phone E-mail Company Name Mailing Address City State ZIP Property Owner NO Suffix V. TANK INFORMATION Capacity Gallons Substance Name CAS Component IV. CONTACT INFORMATION FOR Facility Owner Responsible Official Facility Operator Is person below to receive the invoice and registration certificate YES Last Name First Name MI Phone E-mail Company Name Mailing Address City State ZIP Property Owner NO Suffix V. OWNER SIGNATURE My signature represents to the Department that I own or represent the owner of the storage tank s and am aware of the responsibilities and potential liabilities as an owner arising under the Storage Tank and Spill Prevention Act of 1989 and all applicable regulations. OWNER SIGNATURE My signature represents to the Department that I own or represent the owner of the storage tank s and am aware of the responsibilities and potential liabilities as an owner arising under the Storage Tank and Spill Prevention Act of 1989 and all applicable regulations. I am also advised that statements made on this form are made subject to the penalties of 18 PA. C. S*A.