DEPARTMENT OF PLANNING AND NATURAL RESOURCES 
                   DIVISION OF ENVIRONMENTAL PROTECTION 
 
                                   45 Mars Hill                                Cyril E. King Airport 
                            Frederiksted                               Terminal Building, 2nd Floor 
                                   St. Croix, VI  00840                    St. Thomas, VI  00802 
                       (340) 773-1082                                     (340) 774-3320 
                                                                                       
 
        APPLICATION FOR PERMIT TO USE/OPERATE UST SYSTEM 
TYPE OF ACTION               □ 1. NEW PERMIT     □ 2.  RENEWAL PERMIT 
(Check one item only)                                                                                                    
   □ $500 APPLICATION FEE PAID (Account NO: RV 4421) 
                                                                                                                 400 
I. 
FACILITY / SITE INFORMATION 
 
BUSINESS NAME   
 
FACILITY ID# 
(For Office Use) 
 
 
 
 
 
 
 
 
 
 
 
 
LOCATION OF TANK (Address)                                                             401 
 
FACILITY OWNER TYPE                                                                                           402 
□  1.  CORPORATION     □  4.  LOCAL/PUBLIC AGENCY* 
□  2.  INDIVIDUAL           □  5.  OTHER __________________ 
□  3.  PARTNERSHIP                                                              
*  If owner of UST is a public agency: name of supervisor of division,   section or office which 
     operates the UST  (This is the contact person for the tank records)                                                              
                                                                                                                                                                                     406 
BUSINESS  □  1. GAS STATION   □  2.  COMMERCIAL  
TYPE         □  3. OTHER _______________________                                   403  
TOTAL NUMBER OF TANKS 
                                                                                 
                                                404     
Is facility on Government 
Property?  
□  YES    □  NO               405  
FACILITY INFORMATION       □  1. EPA-FORM 7530-1 (9-98)   ATTACHED           □   3.  PARCEL ID No:______________________________________________  
                                             □  2.  SITE  PLAN  ATTACHED                        □   4. FILED UST @ RECORDER OF DEEDS                                                            
II. 
PROPERTY OWNER INFORMATION 
 
PROPERTY OWNER NAME   
                                                                                                                                                                                                                                                   407 
PHONE 
                                                                                                                          
                                                                                                               408 
MAILING ADDRESS 
                                                              
                                                                                                                                                                                                                                                                                                                                                                                  409 
CITY   
                                                                                                                                                                           410 
STATE 
                                                                                              411 
ZIP CODE 
                                                                            412 
PROPERTY OWNER TYPE         □  1.  CORPORATION                □ 3.  PARTNERSHIP                        □  5.  OTHER                                                 413 
                                       □ 2.   INDIVIDUAL                 □4.  LOCAL AGENCY                                                                               
III. 
TANK OWNER INFORMATION 
 
TANK OWNER NAME 
                                                                                                                                                                                                                                                    414 
 PHONE      
                                                                   415     
MAILING ADDRESS  
                                                                                                                                                                                                                                                                                                                                                                                 416 
CITY   
                                                                                                                                                                          417 
STATE 
                                                                                              418 
ZIP CODE 
                                                                           419 
TANK OWNER TYPE       □  1.  CORPORATION                           □   4.  LOCAL AGENCY                                                                                  
                                      □  2.  INDIVIDUAL                                □  5.  OTHER ________________________ 
                                □  3.  PARTNERSHIP                                                                                                                                                                                                                                                          420 
IV. 
PETROLEUM UST FINANCIAL RESPONSIBILITY 
 
INDICATE METHOD(S)      □  1.  SELF-INSURED             □  3.  INSURANCE                                     □  5.  EXEMPTION                                                 422 
                                       □  2.  GUARANTEE                □   4.  LETTER OF CREDIT                               □ 6.  OTHER ________________________    
V. 
LEGAL NOTIFICATION AND MAILING ADDRESS 
 
Check one box to indicate which address should be used for legal notification and mailing.                                                                                                                                                                                                        423 
  Legal  notification and mailings will be sent to the tank owner unless box 1 or 2 is checked.  □  1.  FACILITY   □  2.   PROPERTY  OWNER  □  3.  TANK OWNER 
 
VI. 
APPLICANT SIGNATURE 
 
Certification – I certify that the information provided is true and accurate to the best of my knowledge. 
SIGNATURE OF APPLICANT 
 
DATE 
                                                                                  424 
PHONE 
                                                                                                   425 
NAME OF APPLICANT (Print) 
                                                                                               
                                                                                                426     
TITLE OF APPLICANT 
 
                                                                                                                                                                                                   428 
1998 UPGRADE NUMBER (For Local Use Only)   
  
                                                                                              429    
 (    )  APPROVED       (     ) DISSAPPROVED    Certificate MAILED _____________ DELIVERED _______________ 
 
DPNR-UST– FORM A (10/03)