Schedule D "Tank Removal Notice Form" - New Brunswick, Canada

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Download Schedule D "Tank Removal Notice Form" - New Brunswick, Canada

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Site File #: 6535-
SCHEDULE - D
(Revised May 2019)
TANK REMOVAL NOTICE FORM
FOR OFFICE USE ONLY
Distribution List:
Installer
Occurrence File #:
DELG Regional Office
DELG Central Office
The New Brunswick Department of Environment and Local Government (NBELG) requires that this
Schedule D form be completed and submitted to the NBELG immediately after the removal of any
petroleum storage system on a site in the province of New Brunswick having a total capacity greater
than or equal to 2,000 litres of petroleum product storage capacity.
• All removal activities are to be completed under the direct supervision of a contractor
holding a current Petroleum Installer License in the Province of New Brunswick.
• All petroleum storage removal activities to be undertaken are to be arranged five (5)
working days in advance of the removal date by contacting the appropriate NBELG
Regional Office, shown on the list provided on page 4 of this form.
• In the event the site and/or tanks on the site where the removal is being completed is not
presently registered with the NBELG, a Schedule B form is to be completed and
attached with the submission of this form. Please contact (506) 453-7945 to verify site
registration and/or for information.
• The Petroleum Product Storage and Handling Regulation requires any person who
suspects or detects that a petroleum product is leaking or has leaked from a storage tank
system to immediately notify the Minister (or designate) of such leak.
Page 1 of 4
Site File #: 6535-
SCHEDULE - D
(Revised May 2019)
TANK REMOVAL NOTICE FORM
FOR OFFICE USE ONLY
Distribution List:
Installer
Occurrence File #:
DELG Regional Office
DELG Central Office
The New Brunswick Department of Environment and Local Government (NBELG) requires that this
Schedule D form be completed and submitted to the NBELG immediately after the removal of any
petroleum storage system on a site in the province of New Brunswick having a total capacity greater
than or equal to 2,000 litres of petroleum product storage capacity.
• All removal activities are to be completed under the direct supervision of a contractor
holding a current Petroleum Installer License in the Province of New Brunswick.
• All petroleum storage removal activities to be undertaken are to be arranged five (5)
working days in advance of the removal date by contacting the appropriate NBELG
Regional Office, shown on the list provided on page 4 of this form.
• In the event the site and/or tanks on the site where the removal is being completed is not
presently registered with the NBELG, a Schedule B form is to be completed and
attached with the submission of this form. Please contact (506) 453-7945 to verify site
registration and/or for information.
• The Petroleum Product Storage and Handling Regulation requires any person who
suspects or detects that a petroleum product is leaking or has leaked from a storage tank
system to immediately notify the Minister (or designate) of such leak.
Page 1 of 4
Site File No.
Occurrence File No.
1. TANK LOCATION INFORMATION
Name of Facility:
Street Address:
Locality:
County:
PID #:
2. TANK OWNERSHIP INFORMATION
Owners Name:
Mailing Address:
Street Address:
Postal Code
Contact Name:
Phone: (
)
Fax: (
)
Owner Email:
Page 2 of 4
3. TANK REMOVAL INFORMATION
DELG
CONTENTS/CAPACITY
DECOMMISSIONING SITE
TANK #
DATE OF REMOVAL:
4. CERTIFICATION
I certify that to the best of our knowledge, the information provided in this form is true, accurate and
complete.
NAME OF INSTALLER:
LICENSE #:
SIGNATURE OF INSTALLER:
DATE:
COMPANY NAME:
For office use only
DELG INSPECTOR WAS NOT ON SITE DURING THE TANK REMOVAL.
APPLICATION RECEIVED BY:
.
SIGNATURE OF DELG INSPECTOR:
.
Page 3 of 4
REGIONAL OFFICE CONTACT INFORMATION
Region
Telephone
Location Address
_____
1
(506) 547-2092
159 Main Street
Suite 202
Bathurst NB
E3A 1A6
2
(506) 778-6032
316 Dalton Avenue
Miramichi NB
E1V 3N9
3
(506) 856-2374
355 Dieppe Blvd
Suite C
Moncton NB
E1A 8L5
4
(506) 658-2558
8 Castle Street
Saint John NB
E2L 3B8
5
(506) 444-5149
20 McGloin Street
Fredericton NB
E3A 5T8
6
(506) 473-7744
65 Broadway Blvd
Grand Falls NB
E3Z 2J6
Forms are available from any regional office of the Department of Environment and Local
Government, or by calling (506) 453-7945.
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