PUBLIC TANK ABANDONMENT

Schedule Job Date (Value Required)

Paid By (Value Required)

CONTRACTOR

HOMEOWNER

Contractor (Value Required)

Street Number (Value Required)

Street Name (Value Required)

Street Type

Village (Value Required)

State (Value Required)

Zip Code (Value Required)

Telephone (Value Required)

E-Mail

First Name (Value Required)

Last Name (Value Required)

Telephone (Value Required)

E-Mail (Value Required)

Street Number (Value Required)

Street Name (Value Required)

Street Type

Village (Value Required)

State (Value Required)

Zip Code (Value Required)

Tank Size (Value Required)

Fill Material (Value Required)

Tank Location --- (Example... Tank is located in the back of the house.) (Value Required)

Notes

Tank Size

Tank Type

Spill Number

Tank Contents

Other

Gas Conversion (Value Required)

Yes

Please enter a tank size and location.

Tank Size

Location

HIDE REGION

Spill Number

(Value Required)

Expected format: DD-MON-RR

Late Notification

Error Date

Zip Code

Village (Value Required)

Zip (Value Required)

Branch To

Towns

Towns2

Zip Code2

Street 2

Town Hold

Confirmation Year

Confirmation day

New Date

Expected format: DD-MON-RR

Cost Stored

Res Type

Res Type Cnt

Res Conf Year

Res Conf Month

Ab Credit Cost

Confirmation Month

Refund Flag

FULL CON ADDRESS

Payment Type

Individual Cost

Entered As

Article XI Notice

*** All removals / abandonments, installactions etc. must be done in accordance with Article XI of the Nassau County Public Health Ordinance. This form is to be used only when the individual storage tank capacity is 1,100 gallons or less .

Application CSS

Oil Tank Abandonment

Date & Payment Information

Contractor

Homeowner

Homeowner

Tank Information

Inspection Notes

Second Tank Information

New Installation

HIDE REGION

Article XI Notice