APPLICATION FOR UNDERGROUND STORAGE TANKS CLOSURE PERMIT
Underground Storage Tanks - City of Claremont
Underground Storage Tanks - City of Claremont
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Claremont Fire Department<br />
Fire Prevention Office<br />
Captain Cullen S. Downing<br />
100 Broad Street<br />
Claremont, New Hampshire 03743<br />
Ph: (603) 542-5156<br />
Fax: (603) 542-7028<br />
Email: firecode@claremontnh.com<br />
<strong>APPLICATION</strong> <strong>FOR</strong> <strong>UNDERGROUND</strong><br />
<strong>STORAGE</strong> <strong>TANKS</strong> <strong>CLOSURE</strong> <strong>PERMIT</strong><br />
Date Issued___________________ Expiration Date___________________ Permit #___________________<br />
_________________________________________<br />
Applicant<br />
__________________________________________<br />
Applicant’s Phone<br />
_______________________________ ________________________________________ _________________<br />
Applicant’s Address City & State Zip<br />
_________________________________________<br />
Site Name<br />
_________________________________________<br />
Property Owner<br />
__________________________________________<br />
Street Address<br />
__________________________________________<br />
Property Owner’s Phone<br />
_______________________________ ________________________________________ _________________<br />
Property Owner’s Address City & State Zip<br />
Date of proposed work__________________________________<br />
Tank # 1 Tank # 2<br />
To be Closed _____Tank _____Pipe To be Closed _____Tank _____Pipe<br />
Tank Capacity (gallons)<br />
Tank Capacity (gallons)<br />
Substance Stored<br />
Substance Stored<br />
Product Pipe Length and Diameter<br />
Product Pipe Length and Diameter<br />
Vent Pipe Length and Diameter<br />
Vent Pipe Length and Diameter
Claremont Fire Department<br />
Fire Prevention Office<br />
Captain Cullen S. Downing<br />
100 Broad Street<br />
Claremont, New Hampshire 03743<br />
Ph: (603) 542-5156<br />
Fax: (603) 542-7028<br />
Email: firecode@claremontnh.com<br />
Month/Year tank(s) last used:__________________________________________________________________<br />
Where will liquids and sludge be disposed of?_____________________________________________________<br />
Will soil analysis be performed? ____Yes ____No<br />
If yes by whom:____________________________________________________________________________<br />
Describe closure and any special circumstances or requirements______________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
I certify that the information contained in this application is true and correct, and that I am authorized to request<br />
a permit for the proposed action(s).<br />
Applicant Signature:____________________________________________________ Date:________________<br />
I am the:<br />
____Property Owner ____Contractor
Claremont Fire Department<br />
Fire Prevention Office<br />
Captain Cullen S. Downing<br />
100 Broad Street<br />
Claremont, New Hampshire 03743<br />
Ph: (603) 542-5156<br />
Fax: (603) 542-7028<br />
Email: firecode@claremontnh.com<br />
STATEMENT<br />
I HEREBY ACKNOWLEDGE THAT, I HAVE READ THIS <strong>APPLICATION</strong>, THAT THE IN<strong>FOR</strong>MATION<br />
GIVEN IS CORRECT AND THAT I AM THE OWNER, OR DULY AUTHORIZED TO ACT IN THE<br />
OWNER’S BEHALF AND SUCH HEREBY AGREE TO COMPLY WITH THE APPLICABLE<br />
REQUIREMENTS OF THE FIRE PREVENTION CODE. IT IS FURTHER UNDERSTOOD THAT THIS<br />
<strong>APPLICATION</strong> DOES NOT CONSTITUTE A <strong>PERMIT</strong> AND IS NOT A LICENSE.<br />
_________________________________________<br />
Printed Name<br />
__________________________________________<br />
Signature<br />
_________________________________________<br />
Title<br />
DO NOT WRITE BELOW THIS LINE________________________________<br />
Comments_________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
Approved____ Disapproved____ Reason for Disapproval_________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
__________________________________________________________________________________________<br />
_________________________________________<br />
Fire Official - Printed Name<br />
__________________________________________<br />
Signature<br />
Claremont Fire Department
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