DHEC Form 4075 "Tank Owner Information Form" - South Carolina

What Is DHEC Form 4075?

This is a legal form that was released by the South Carolina Department of Health and Environmental Control - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DHEC Form 4075 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 4075 "Tank Owner Information Form" - South Carolina

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Underground Storage Tank Management Division
Tank Owner Information Form
Facility Name:
Permit ID:
Release Date(s):
Facility Address:
City:
Zip Code:
South Carolina
Tank Owner Name:
Mailing Address:
City:
State:
Zip Code:
Name of Tank Owner (or Authorized Agent if Owner is a Business Entity) (print):
Signature:
Date:
If you are a sole proprietor as the tank owner and choose to not to have any agents, please initial _________, identifying you are the
only person authorized to sign invoices and/or select a certified site rehabilitation contractor for the referenced release(s).
I certify that the agents identified below are authorized to select a certified site rehabilitation contractor and/or sign invoices on
behalf of the tank owner for compensation from SUPERB Account for site rehabilitation activities conducted under the UST release(s)
referenced above; print name, affiliation with tank owner, and signature (non-black ink). ________ (tank owner initial)
Authorized to sign invoices on
Authorized to select a certified
behalf of the tank owner
site rehabilitation contractor
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
D-4075 7/20
Underground Storage Tank Management Division
Tank Owner Information Form
Facility Name:
Permit ID:
Release Date(s):
Facility Address:
City:
Zip Code:
South Carolina
Tank Owner Name:
Mailing Address:
City:
State:
Zip Code:
Name of Tank Owner (or Authorized Agent if Owner is a Business Entity) (print):
Signature:
Date:
If you are a sole proprietor as the tank owner and choose to not to have any agents, please initial _________, identifying you are the
only person authorized to sign invoices and/or select a certified site rehabilitation contractor for the referenced release(s).
I certify that the agents identified below are authorized to select a certified site rehabilitation contractor and/or sign invoices on
behalf of the tank owner for compensation from SUPERB Account for site rehabilitation activities conducted under the UST release(s)
referenced above; print name, affiliation with tank owner, and signature (non-black ink). ________ (tank owner initial)
Authorized to sign invoices on
Authorized to select a certified
behalf of the tank owner
site rehabilitation contractor
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
Name:
Affiliation:
Yes
No
Yes
No
Signature:
Date:
D-4075 7/20
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Instructions for Completing
DHEC FORM 4075 Tank Owner Information Form
Purpose
Identify appropriate tank owner(s), operators, authorized personnel, or agents.
Tank Owner of UST release sites and/or other authorized agent(s).
Item-by-item instructions for completing the form.
• Fill in all information for Tank Owner box.
• Address all statements and answer all applicable questions by recording information in the appropriate
blanks.
• Each individual identified must sign and date the form where appropriate.
• Form is scanned and saved electronically - Record Group Number 169, Retention Schedule
• 13300
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