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.