Schedule A "Part Iii - Project Completion" - New Brunswick, Canada

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Download Schedule A "Part Iii - Project Completion" - New Brunswick, Canada

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Site File #: 6535-
SCHEDULE – A, PART III
(Revised January 2018)
PROJECT COMPLETION
FOR OFFICE USE ONLY
Distribution List:
Project File #:
Senior App. Eng
Data Manager
The information supplied in this application is to confirm that the new installation or modification to
an existing system is completed and conforms to the Department’s Construction Standards for
Installation and Removal of Petroleum Storage Systems. The completed form shall be forwarded to
the Department immediately upon completion of the installation.
Please forward this application to:
New Brunswick Department of Environment and Local Government
Authorizations Branch
(20 McGloin Street, Fredericton, NB E3A 5T8)
P.O. Box 6000
Fredericton, New Brunswick
E3B 5H1
Telephone: (506) 453-7945
Fax: (506) 453-2390
Page 1 of 3
Site File #: 6535-
SCHEDULE – A, PART III
(Revised January 2018)
PROJECT COMPLETION
FOR OFFICE USE ONLY
Distribution List:
Project File #:
Senior App. Eng
Data Manager
The information supplied in this application is to confirm that the new installation or modification to
an existing system is completed and conforms to the Department’s Construction Standards for
Installation and Removal of Petroleum Storage Systems. The completed form shall be forwarded to
the Department immediately upon completion of the installation.
Please forward this application to:
New Brunswick Department of Environment and Local Government
Authorizations Branch
(20 McGloin Street, Fredericton, NB E3A 5T8)
P.O. Box 6000
Fredericton, New Brunswick
E3B 5H1
Telephone: (506) 453-7945
Fax: (506) 453-2390
Page 1 of 3
1. FACILITY DESCRIPTION
Facility Name:
Street Address:
Mailing Address:
Postal Code:
Telephone: (
)
Email:
2. AS-BUILT DRAWING
Attach a copy of the revised engineering construction drawings/plot plan to indicate
the final as-built dimensions of the installation. The drawings are to be stamped by an
engineer who has a license to practice in the Province of New Brunswick.
Page 2 of 3
3. INSTALLER CERTIFICATION
Name of Licensed Installer:
Installer License No.:
Company Name: _______________________________________________________
Date of Completion of Installation:
Number of Old Tanks Removed:
Description of New Tanks Installed:
Tank 1
Tank 2
Tank 3
Tank 4
Tank 5
Tank 6
Capacity (L)
Contents
Material
I certify that as the installer, I have completed the installation in accordance with the
plans and any and all codes, specifications, and regulations that apply to this facility.
Signature of Licensed Installer:
Date:
4. APPLICANT CERTIFICATION
I certify that to the best of my knowledge, the information provided in this form is
true, accurate, and complete.
Name of applicant:
Signature:
Date:
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