TCEQ Form 20092 "Tceq - Dry Cleaning Facility Registration Form" - Texas

TCEQ Form 20092 is a Texas Commission on Environmental Quality form also known as the "Tceq - Dry Cleaning Facility Registration Form". The latest edition of the form was released in June 3, 2016 and is available for digital filing.

Download a PDF version of the TCEQ Form 20092 down below or find it on Texas Commission on Environmental Quality Forms website.

ADVERTISEMENT

Download TCEQ Form 20092 "Tceq - Dry Cleaning Facility Registration Form" - Texas

1122 times
Rate
(4.8 / 5) 67 votes
DCR /
/ CO /
/ FAC
For internal use only
TCEQ - DRY CLEANING FACILITY REGISTRATION FORM
Mail completed form to:
TCEQ Account No. :
Texas
Texas Commission on Environmental Quality
For Use
Commission
Dry Cleaning Registration Team (MC-138)
Federal Tax ID No. :
in
on
P. O. Box 13087
Texas
Environmental
Austin, Texas 78711-3087
Taxpayer ID No.:
Quality
(512) 239-2160 and fax # (512) 239-3398
TCEQ rules (Title 30 Tex. Admin. Code Ch. 337) state that annual renewal registration forms are due by August 1st of each year.
For each drop station, complete a separate Dry Cleaning Drop Station Registration Form (Form #20207)
Section 1. Reason For Filing the Form
(Check all that apply).
1
Initial Registration 2
Renewal Registration 3
Ownership Change (indicate effective date) _____/______/_____
4
No longer a facility (Indicate effective date of the closing of the facility) ______/______/______
5
Change from drop station to facility (Indicate effective date of change) _____/_____/_____
6
Amendment of:
Owner Information
Facility Information
Real Property Owner
Solvent Information
Dry Cleaning Machine Information
Other_______________________________
Section 2. Owner Information
Customer No.: CN ______________________
Owner Name: Business Name or Last Name: ____________________________________First Name_____________________________
Mailing Address:____________________________________________City:_____________________State:________Zip Code:__________
Billing Address (if different):____________________________________City: __________________State:________ Zip Code:__________
Country (Outside USA) :____________________ Email Address :____________________________________________________
Owner's Authorized Representative: ______________________________ Title: _________________Phone No: ______/_____-______
Type of Owner:
Individual
Sole Proprietorship DBA
Corporation
Partnership
Other _______________
Location of Records:
At facility
Offsite at: Address:_____________________________City:_________________State:_______
Records Custodian/Contact Person: ________________________Phone No.:______/______-______Fax No : _____/______-______
State Franchise Tax ID: ______________________ DUNS No. :______________________
Independently Owned & Operated:
Yes
No # of Employees:
0-20
21-100
101-250
251-500  501 & Higher
**This form will not be processed until all delinquent fees and/or penalties owed to the TCEQ or the Office of the Attorney
.**
General on behalf of the TCEQ are paid in accordance with the
Delinquent Fee and Penalty Protocol
Have you ever used or allowed the use of the dry cleaning solvent perchloroethylene at a dry cleaning facility
or drop station in this state?
Yes
No
Has the dry cleaning solvent perchloroethylene ever been used at this location?
Yes
No
Section 3. Facility Information
Regulated Entity No.: RN __________________
Facility Name: ____________________________________ Street Address:______________________________________________
City: _______________________TEXAS Zip Code: _________County:_____________ Contact Person:_________________________
Title:_________________ Phone No.:_____/______-______ Email Address :_________________________Fax No.:_____/_____-____
Primary SIC Code: ______ Secondary SIC: ______
Primary NAICS Code: _______ Secondary NAICS: ________
Latitude: Degrees _____Minutes _____Seconds _____ Longitude: Degrees ______Minutes______ Seconds_______
Does this dry cleaning facility accept payment directly from retail customers?
Yes
No
Please indicate gross receipts (includes all sources of income from this location, including laundry receipts) for the last
consecutive 12 months reported to the Comptroller: (If facility does not collect money from retail customers, use gross
receipts from associated drop stations.)
$150,000 or less
more than $150,000
This number should be the same as the “Total Sales” line on your Sales & Use Tax Return.
Gross receipts will be verified by the Texas Comptroller of Public Accounts
(If this information is not verified to be accurate, your dry cleaning registration certificate may be withheld)
When did you begin dry cleaning operations at this location? _____/______/_______
Was this location ever a dry cleaning facility prior to the date you began operations?
Yes or
No
Please complete a separate form for each dry cleaning facility
TCEQ-20092(Rev 6/3/2016)
DCR /
/ CO /
/ FAC
For internal use only
TCEQ - DRY CLEANING FACILITY REGISTRATION FORM
Mail completed form to:
TCEQ Account No. :
Texas
Texas Commission on Environmental Quality
For Use
Commission
Dry Cleaning Registration Team (MC-138)
Federal Tax ID No. :
in
on
P. O. Box 13087
Texas
Environmental
Austin, Texas 78711-3087
Taxpayer ID No.:
Quality
(512) 239-2160 and fax # (512) 239-3398
TCEQ rules (Title 30 Tex. Admin. Code Ch. 337) state that annual renewal registration forms are due by August 1st of each year.
For each drop station, complete a separate Dry Cleaning Drop Station Registration Form (Form #20207)
Section 1. Reason For Filing the Form
(Check all that apply).
1
Initial Registration 2
Renewal Registration 3
Ownership Change (indicate effective date) _____/______/_____
4
No longer a facility (Indicate effective date of the closing of the facility) ______/______/______
5
Change from drop station to facility (Indicate effective date of change) _____/_____/_____
6
Amendment of:
Owner Information
Facility Information
Real Property Owner
Solvent Information
Dry Cleaning Machine Information
Other_______________________________
Section 2. Owner Information
Customer No.: CN ______________________
Owner Name: Business Name or Last Name: ____________________________________First Name_____________________________
Mailing Address:____________________________________________City:_____________________State:________Zip Code:__________
Billing Address (if different):____________________________________City: __________________State:________ Zip Code:__________
Country (Outside USA) :____________________ Email Address :____________________________________________________
Owner's Authorized Representative: ______________________________ Title: _________________Phone No: ______/_____-______
Type of Owner:
Individual
Sole Proprietorship DBA
Corporation
Partnership
Other _______________
Location of Records:
At facility
Offsite at: Address:_____________________________City:_________________State:_______
Records Custodian/Contact Person: ________________________Phone No.:______/______-______Fax No : _____/______-______
State Franchise Tax ID: ______________________ DUNS No. :______________________
Independently Owned & Operated:
Yes
No # of Employees:
0-20
21-100
101-250
251-500  501 & Higher
**This form will not be processed until all delinquent fees and/or penalties owed to the TCEQ or the Office of the Attorney
.**
General on behalf of the TCEQ are paid in accordance with the
Delinquent Fee and Penalty Protocol
Have you ever used or allowed the use of the dry cleaning solvent perchloroethylene at a dry cleaning facility
or drop station in this state?
Yes
No
Has the dry cleaning solvent perchloroethylene ever been used at this location?
Yes
No
Section 3. Facility Information
Regulated Entity No.: RN __________________
Facility Name: ____________________________________ Street Address:______________________________________________
City: _______________________TEXAS Zip Code: _________County:_____________ Contact Person:_________________________
Title:_________________ Phone No.:_____/______-______ Email Address :_________________________Fax No.:_____/_____-____
Primary SIC Code: ______ Secondary SIC: ______
Primary NAICS Code: _______ Secondary NAICS: ________
Latitude: Degrees _____Minutes _____Seconds _____ Longitude: Degrees ______Minutes______ Seconds_______
Does this dry cleaning facility accept payment directly from retail customers?
Yes
No
Please indicate gross receipts (includes all sources of income from this location, including laundry receipts) for the last
consecutive 12 months reported to the Comptroller: (If facility does not collect money from retail customers, use gross
receipts from associated drop stations.)
$150,000 or less
more than $150,000
This number should be the same as the “Total Sales” line on your Sales & Use Tax Return.
Gross receipts will be verified by the Texas Comptroller of Public Accounts
(If this information is not verified to be accurate, your dry cleaning registration certificate may be withheld)
When did you begin dry cleaning operations at this location? _____/______/_______
Was this location ever a dry cleaning facility prior to the date you began operations?
Yes or
No
Please complete a separate form for each dry cleaning facility
TCEQ-20092(Rev 6/3/2016)
CN # _________________________________
RN # ____________________________________
Section 4. Real Property Owner
Name: ______________________________________Contact Person: __________________________Phone No: ______/_____-_____
Mailing Address:__________________________________________City:_____________________State______________Zip_________
Section 5. TCEQ Programs in which this Regulated Entity Participates
Dry Cleaning
New Source Review - Air
Industrial & Hazardous Waste
Petroleum Storage Tank
Title V - Air
Wastewater Permit
Water Rights
Animal Feeding Operation
Water Districts
Municipal Solid Waste
Water Utilities
Licensing - Type (S)
Unknown
Other _______________________________________________
Section 6. Description of Dry Cleaning Machines and Facility
(Complete for each machine currently at this location.) If
more than four machines, please complete a separate form.
a. Dry cleaning machine identification number
Machine No.
Machine No.
Machine No.
Machine No.
(assigned by owner, i.e., 1, 2, 3)
b. Dry cleaning machine installation date (mm/yyyy)
______/_______
______/_______
______/_______
______/_______
c.
Status of dry cleaning machine:
Currently in use? (yes or no) If not, is the machine:
Yes
No
Yes
No
Yes
No
Yes
No
Temporarily out of use, since (mm/yyyy); OR
______/_______
______/_______
______/_______
______/_______
Permanently out of use, since (mm/yyyy)
______/_______
______/_______
______/_______
______/_______
If permanently out of use, has the machine been emptied of
all dry cleaning solvents? (yes or no)
Yes
No
Yes
No
Yes
No
Yes
No
d. Does dry cleaning machine have secondary
containment? (Indicate Yes or No)
Yes
No
Yes
No
Yes
No
Yes
No
If yes, when was it installed? (mm/yyyy)
______/_______
______/_______
______/_______
______/_______
Indicate material of construction for containment:
______________
______________
______________
______________
Section 7. Solvent Purchase, Use, Delivery, Storage, and Disposal
a.
From whom do you purchase solvent?
1. Distributor Name: ___________________________________TCEQ Distributor ID # _____________________
2. Distributor Name: ___________________________________TCEQ Distributor ID # _____________________
b. Check type of solvents currently used:
Perc
Petroleum
Carbon Dioxide
Other (Specify)________________________
c.
Check type of solvents used in the past at this location:
Perc
Petroleum
Other (Specify)________________________
d. What is the number of gallons purchased annually? Perc ____________ Petroleum _____________Other (Specify)__________________
e.
Are virgin (new) solvents stored in containers other than in the drycleaning machine?
Yes
No
Is there secondary containment around the storage area?
Yes
No
Indicate material of construction for the secondary containment: _________________________________________________________
f.
Are chlorinated dry cleaning solvents delivered to the
g. If chlorinated dry cleaning solvents are used, are wastes (muck,
facility by a closed, direct-coupled delivery system?
filter, etc.) stored in sealed containers marked “hazardous waste”?
Yes
No
Yes
No
Section 8. Associated Drop Stations
a. How many dry cleaning drop stations are currently owned by the dry cleaning facility owner? ________________
b. As of the date of this form, is the drop station registration information on file with the TCEQ, including information on this
form, complete, accurate, and up to date?
Yes
No
N/A
c. If any previously owned drop stations have permanently ceased operations or are no longer owned by the facility
owner, please indicate the drop station’s change in status in a separate Dry Cleaning Drop Station Registration Form
(Form #20207).
For each drop station, complete a separate Dry Cleaning Drop Station Registration Form (Form #20207)
Section 9. Certification
The signature below indicates that I have personal knowledge of all the facts set forth in this document and all attached
documents, and am able to certify, and I do certify, that all the facts and statements in this document and all attached documents
are true, accurate, complete, and correct.
Signature of Owner or Legal Representative____________________________________________ Date _______/ _______/________
Print Name of Owner or Legal Representative ____________________________________Title__________________________________
To request and review your personal information gathered by the agency, or correct any errors in your information, contact us at (512) 239-2160.
TCEQ-20092(Rev 6/3/2016)
ADVERTISEMENT
Page of 2