Zip Code:

State:CityAddress:

Phone:Name:

RESPONSIBILITY FOR COST OF REMEDIATION

Temporary Out-of-service Storage Facility

Temporary Storage Facility Out-of-service Storage Facility

Short Term Storage FacilityLong Minimal Storage Facility

Existing Long Term Storage FacilityNew Long Term Storage Facility

(Check as applicable)PERMIT CLASSIFICATION REQUESTED

ModificationRenewalNewTemporaryProvisionalFull

(Check as applicable)TYPE OF PERMIT

Zip Code:

State:CityAddress:

Fax:Phone:Name:

OWNER OR OPERATOR

PIN:email:

Fax:Phone:Zip Code:State:

City:Address:

FACILITY IDENTIFICATION

Name of Facility

Date:

City of Laredo Environmental Services Department

Hazardous Materials Division Hazardous Materials Management Permit

(956)794-1650

EMERGENCY CONTACT

Address:

Zip Code:

State:City

24 Hour Phone:Name:

ATTACHMENTS/INCLUSIONS REQUIRED (Check to indicate inclusion)

Hazardous Materials Management Plan

Construction Plans for LTST per Sec. 33-71

General Site Plan in HMMP

Drawing of Drainage System Mgt.

Closure Plan (per Sec 33-19 if applicable)

Emergency Response Plan

Permit FeeHazardous Materials Inv. Statement

Building Floor Plan in HMMP

Drawing of Separation of Incompat. Mat'ls.

Employee Training Certification

Permit Quantity Limit Requested

Proof of Liability Insurance

AUTHORIZED REPRESENTATIVE SUBMITTING APPLICATION

Name: Title:

SIGNATURE DATE:

FOR OFFICIAL USE ONLY

Date Approved:

Approved By:

Signature:

Receipt #:

FeeAttched:

Permit Number:

Check No. Date:

Lock No.

Date Disapproved:

Disapproved By:

Signature:

Reasons:

NOTE: No refund or rebate of a permit fee shall be allowed by reason of the fact that the permit is denied or the permittee discontinues the activity or use of a facility prior to the expiration of the term or that the permit is suspended or revoked prior to the expiration of the term.