Date Su
b
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Inst
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Und
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Address:
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Locatio
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Contrac
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Complet
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C
N
2.
N
3.
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4.
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5.
A
Failure
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A
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Name:
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of Tank(s):
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Applic
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rest, NC 27587
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e implied dis
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significant e
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e
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d
onmen
t
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ns Department
| Phone: (919) 4
3
T
estin
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e Ground T
a
t
ate:
CAPACIT
Y
i
de all requir
e
n
stallation, e
x
t
anks.
T
he f
o
of Environ
m
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ing the capa
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p
osition of t
h
l
ements of t
h
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ms will res
u
the Inst
t
of Und
e
o
rage Ta
| 301 South Bro
o
3
5-9530 | Fax: (
9
g
a
nk
Contact:
Phone:
Y
Contractor’
Phone:
State:
Title:
Mobile No.
e
d informati
o
x
cavation, re
m
o
llowing ite
m
m
ent, Health
c
ity and cont
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h
e tanks post
-
h
e tank remo
v
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lt in delay
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t
allation,
e
rgroun
d
nks
o
ks Street
9
19) 435-9538
F
Chang
e
Piping Syst
e
T
AN
K
s N.C. ID#:
:
o
n at least fo
u
m
oval, testin
g
m
s are
requi
re
and Natural
e
nts of each
t
-
removal.
v
al/abandon
m
o
r refusal to
Date:
Date:
d
or
F
ee: $100.00
(
e
-in-Service
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m
Zip:
K
CONTE
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Zip:
u
rteen (14) d
a
g
, closure or
red
to be sub
m
Resources
G
t
ank.
m
ent site.
issue this p
e
(
per tank)
N
TS
a
ys prior to
r
change-in-
m
itted with
G
W/NST-3
e
rmi
t
.
click to sign
signature
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