UST Permit Application

SECTION A – GENERAL INFORMATION
Facility Address
Facility Address
Business Mailing Address
Business Mailing Address
Designated signatory authority of the facility
Designated signatory authority of the facility
Designated Facility Contact
Designated Facility Contact
Phone
Phone
SECTION B – EFFLUENT DISCHARGE INFORMATION
AUTHORIZED REPRESENTATIVE STATEMENT
AUTHORIZED REPRESENTATIVE STATEMENT
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Date
Date
Entering your name attests your electronic signature.