Tank Abandonment Removal Permit Application

INSTRUCTIONS: This application shall be filled out in its entirety. You must also submit a Nassau County Home Improvement License, as well as General Liability and Workman's Compensation with the certificate holder being: Inc. Village of East Rockaway, 376 Atlantic Avenue, East Rockaway, NY 11518, along with this application. According to Article XI of the Nassau County Public Health Ordinance you must notify the Nassau County Health Department prior to any tank abandonment or removal. You can contact the NC Department of Health located at The Bureau of Environmental Protection, Nassau County Department of Health, 240 Oid Country Road, Mineola, New York, 11501, or on their website at http://www.nassaucountyny.gov or by calling (516) 571-2406.

For Office Use Only:

Fee: Permit #: Date:

Owner: Tel #:

Official Address Permit Applied For: Zone:

Current use:

Village Section: Village Block: Village Lot(s):

Remove an in ground oil storage tank:
Abandon in place an in ground oil storage tank:

Location of tank feet from the building on the N.E.S.W. side, feet from street line capacity of tank gallons. Date tank will be hoisted or opened and ready for inspection: .

Please note: a copy of both forms required by the Nassau County Health Department is to be submitted with this application, alone with N.C. Home Improvement License, General Liability and Workman's Comp.

The owner of this building and the undersigned agree to conform to all applicable laws of the Village of East Rockaway.

Please print name: , states that he/she is authorized to make this application and that all statements are true to the best of his/her knowledge and belief. (If corporation, give name of corporation and name, office and address of its responsible officers.)

Signature Date