Schedule A "Part I - Site Approval" - New Brunswick, Canada

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Download Schedule A "Part I - Site Approval" - New Brunswick, Canada

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Site File #: 6535-
SCHEDULE – A, PART I
(Revised July 2019)
SITE APPROVAL
FOR OFFICE USE ONLY
Distribution List:
Data Manager:
Project File #:
Senior App. Eng.:
The information supplied in this application form is for site approval for a new installation or
modification to an existing system, and shall be forwarded to the Department at least one month
prior to the anticipated start of construction. The Department will assess the site sensitivity, based
on the information provided. Within one month of receipt of this application, the Department will
notify the applicant in writing of the requirement for either minimum installation standards or in the
case of sensitive areas, additional leak prevention measures or, subject to the degree of sensitivity,
the proposal may be denied.
NOTE:
An application fee in the amount of $25.00 must accompany this submission.
Failure to do so will result in a delay of the processing of this application.
Cheques are to be made payable to the Minister of Finance. Please forward this application and
applicable fee 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
5
Page 1 of
Site File #: 6535-
SCHEDULE – A, PART I
(Revised July 2019)
SITE APPROVAL
FOR OFFICE USE ONLY
Distribution List:
Data Manager:
Project File #:
Senior App. Eng.:
The information supplied in this application form is for site approval for a new installation or
modification to an existing system, and shall be forwarded to the Department at least one month
prior to the anticipated start of construction. The Department will assess the site sensitivity, based
on the information provided. Within one month of receipt of this application, the Department will
notify the applicant in writing of the requirement for either minimum installation standards or in the
case of sensitive areas, additional leak prevention measures or, subject to the degree of sensitivity,
the proposal may be denied.
NOTE:
An application fee in the amount of $25.00 must accompany this submission.
Failure to do so will result in a delay of the processing of this application.
Cheques are to be made payable to the Minister of Finance. Please forward this application and
applicable fee 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
5
Page 1 of
1. DESCRIPTION OF INSTALLATION OR MODIFICATION
Proposed construction start-up date:
Provide a site sketch identifying the location of existing and new tanks along with any
nearby underground services.
Page 2 of 5
2. FACILITY AND TANK INFORMATION
Name of Facility:
Mailing Address:
Postal Code:
Location Address:
County:
Manager (Chief Operator's) Name:
Mailing Address:
Postal Code:
Residence Address:
Postal Code:
Telephone: (Business)
(Residence)
Name of Owner of System:
Mailing Address:
Postal Code:
Contact Name:
Telephone: (
)
Fax: (
)
Owner Email:
Owner Language Preference (please check):
English
French
Supplier of Gasoline or Associated Product:
Page 3 of 5
3. SITE INFORMATION
PID No.
Property Tax No.
Owner of Land:
Mailing Address:
Postal Code:
Telephone: (
)
Fax: (
)
List the number of wells within the noted distance of the facility location:
Within 300m
Within 1000m
Will the proposed petroleum storage be located within a Wellfield Protected Area?
Yes
No
Will the proposed petroleum storage be located within a Flood Zone?
Yes
No
4. TYPE OF OPERATION
Retail Outlet
Bulk Plant
Not for Profit
Commercial/Industrial/Woodlands
Marina
Residential
Farm
Provincial Government
Municipal Government
Page 4 of 5
5. CORRESPONDENCE
All correspondence concerning this application is to be directed to:
Company:
Attention:
Mailing Address:
Postal Code:
Telephone: (
)
Fax: (
)
Email Address:
6. 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:
Page 5 of 5