2. This is a:*

   1. Permanent Removal
   2. Temporary Closure
3. This application is for the removal of:*

   1. Above Ground Tank(s)
   2. Underground Tank(s)
   3. Other Tank(s)
4. If "Other," please provide details:
6. Request abandon in-place closure?*

   1. Yes
   2. No
7. If yes, what inert solid material is being used to fill the tank?
8. Proposed Date to Begin Closure*
   ** Note: Application must be submitted at least 10 days in advance to allow time for the application to be processed.
10. Do you have fuel dispensing?*

    1. Yes
    2. No
11. If Yes, are dispensers being removed?

    1. Yes
    2. No
12. Proposed Closure Completion Date*
16. Tank Information:
18. 1
20. Number*
21. Type*
22. Capacity*
23. Contents*
25. Number of Baffles*
26. Tank(s) currently in use?*

    1. Yes
    2. No
27. If no, how long have the tank(s) been unused?
28. Is there any product remaining in tank(s)?*

    1. Yes
    2. No
30. 2
32. Number
33. Type
34. Capacity
35. Contents
37. Number of Baffles
38. Tank(s) currently in use?

    1. Yes
    2. No
39. If no, how long have the tank(s) been unused?
40. Is there any product remaining in tank(s)?

    1. Yes
    2. No
42. 3
44. Number
45. Type
46. Capacity
47. Contents
49. Number of Baffles
50. Tank(s) currently in use?

    1. Yes
    2. No
51. If no, how long have the tank(s) been unused?
52. Is there any product remaining in the tank(s)?

    1. Yes
    2. No
54. If more space is needed, please list Type, Number, Capacity, Contents, and Number of Baffles for all additional tanks. Also include whether the tank(s) are currently in use (how long if not) and whether there is any product remaining in the tank(s).
58. Please submit all documentation for soil analysis*
59. Have there been any known leaks with tank(s)?*

    1. Yes
    2. No
60. If yes, please provide all supporting documentation regarding leak(s)
62. Laboratory conducting soil analysis*
64. Lab Billing Address*
66. City*
67. State*
68. Zip*
70. Lab Contact First Name*
71. Lab Contact Last Name*
73. Lab Contact Phone #*
74. Lab Contact Email*
78. Business Name*
80. Business Contact First Name*
81. Business Contact Last Name*
83. Contact Phone Number*
84. Contact Email*
86. Business Billing Address*
88. City*
89. State*
90. Zip*
92. Tax Map Number*
94. Inspection Property Address if different than billing
96. City
97. State
98. Zip
100. Tax Map Number
102. Property Owner:*
104. Property Owner Phone*
105. Property Owner Email*
107. Property Owner Address*
109. City*
110. State*
111. Zip*
115. Contractor removing tank*
     Class A or B Contractor Only
117. Contractor License Number*
118. Is contractor certified in hazardous materials mitigation, removal, and/or transportation?*

     1. Yes
     2. No
119. Please submit hazardous materials certification documentation
121. Contractor (On-Site) Contact First Name*
122. Contractor (On-Site) Contact Last Name*
124. Contractor Contact Phone*
125. Contractor Contact Email*
127. Emergency Phone # 1*
128. Emergency Phone # 2
130. Billing Address for Contractor removing tank*
132. City*
133. State*
134. Zip*
138. Name of facility receiving the removed tank*
     Enter "N/A" if tank is an abandoned in-place closure.
140. Facility Address*
142. City*
143. State*
144. Zip*
146. Facility Phone*
147. Facility Email*
149. Please provide documentation that facility is a certified disposal location for the tank*
     **Note: Upon completion, documentation will also need to be provided that the tank was actually taken to this facility.
153. Acknowledgement*

     I hereby accept full responsibility for the adherence to all requirements of the Virginia Statewide Fire Prevention Code and the City of Waynesboro pertaining to the above application.

     1. I Agree
155. Application Submitted By (First Name)*
156. (Last Name)*
158. Applicant Phone*
159. Applicant Email*
Leave This Blank:


161. 1. Receive an email copy of this form.
162. Email address

     This field is not part of the form submission.

163. Submit Submit and Print

* indicates a required field