Personal Info
Name: Title:
Company:
Address: State:    Zip:
Phone: Fax: Email:

Facility Info
Facility Location (if multiple please indicate) 

Total number of Aboveground Tanks: 

Total Gallons of Oil* on Premises:

*Oil includes petroleum; fuel oil; sludge; oil refuse; oil mixed w/ wastes other than dredged soil; fats, oils or greases of animal, fish/marine mammal origin; vegetable oils, including oil from seeds, nuts, fruits, or kernels; and other oils & greases, including synthetic & mineral oils