Aug 30, 2006 ... Reason For Filing the Form (Check all that apply). 1. Initial Registration 2. Renewal Registration 3. Ownership Change (indicate effe...
Michigan Dry Cleaning Environmental Compliance Workbook Michigan Department of Environmental Quality Environmental Science and Services Division
TCEQ-0659 (Rev. 10/28/2013) For more information, visit our web site at www.tceq.texas.gov . Page 2 of 3 TCEQ Facility ID No TCEQ - AST REGISTRATION FORM
Download 3 or 4 Digit Security Code:______ Credit Card Billing Zip Code:______. EVENT REGISTRATION FORM. PROGRAM TITLE. EVENT CODE. EVENT DATE. PRICE *. TOTAL. If you need more space please duplicate this form. Please fax this completed form wit
lists the name and address of everyone who is registered. By law, certain public organisations and people, including politicians, can receive the full register
Download Event Registration Form (previously the Liquor Permit Form). Event Manager Details. Name: Mobile: Email: Staff/student number: Event Details. Event name: Event location: Event start date: Event end date: Event start time: Event end time:
Download ADULT REGISTRATION ($25) - PLEASE ENCLOSE PAYMENT WITH REGISTRATION FORM. CHILD CARE (BIRTH - 5 YEARS) - MUST SUBMIT HEALTH FORM - CHILD'S AGE: KIDS ASSEMBLY (K - 5th GRADE) - MUST SUBMIT HEALTH FORM - CHILD'S GRADE: YOUTH ASSE
Download Event Registration Form. This form is to be used to register all Student Life supported programs, activities and meetings. Worksheets must be submitted to the Office of Student Life, two (2) weeks in advance of the event. If you have any
Download UNE LIFE EVENT ADMINISTRATION, MADGWICK HALL. P: 02 6773 5705 E: [email protected]. UNE EVENT REGISTRATION FORM. *Must be lodged with the UNE Life Event Administration at least 7 days prior to event for events 100 people. Th
Download Event Registration Form. This form is to be used to register all Student Life supported programs, activities and meetings. Worksheets must be submitted to the Office of Student Life, two (2) weeks in advance of the event. If you have any
Download UNE LIFE EVENT ADMINISTRATION, MADGWICK HALL. P: 02 6773 5705 E: [email protected]. UNE EVENT REGISTRATION FORM. *Must be lodged with the UNE Life Event Administration at least 7 days prior to event for events 100 people. Th
Download 3 or 4 Digit Security Code:______ Credit Card Billing Zip Code:______. EVENT REGISTRATION FORM. PROGRAM TITLE. EVENT CODE. EVENT DATE. PRICE *. TOTAL. If you need more space please duplicate this form. Please fax this completed form wit
Download facility, AAS will refund to attendee his/her paid registration fee minus a portion of the event costs acquired by AAS. This refund will be the attendees' exclusive remedy and AAS' only liability for cancellation of the event for
Download facility, AAS will refund to attendee his/her paid registration fee minus a portion of the event costs acquired by AAS. This refund will be the attendees' exclusive remedy and AAS' only liability for cancellation of the event for
Download ADULT REGISTRATION ($25) - PLEASE ENCLOSE PAYMENT WITH REGISTRATION FORM. CHILD CARE (BIRTH - 5 YEARS) - MUST SUBMIT HEALTH FORM - CHILD'S AGE: KIDS ASSEMBLY (K - 5th GRADE) - MUST SUBMIT HEALTH FORM - CHILD'S GRADE: YOUTH ASSE
Download Event Registration Form (previously the Liquor Permit Form). Event Manager Details. Name: Mobile: Email: Staff/student number: Event Details. Event name: Event location: Event start date: Event end date: Event start time: Event end time:
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Title: Application for Texas Title and/or Registration (Form 130-U) Author: Vehicle Titles and Registration Divison Keywords: Application for Title, Title Only
AHIMA Webinar Registration Form—1 . Visit www.ahima.org for more details . AHIMA WEBINAR REGISTRATION FORM – Register Today and Save! Review our versatile pricing
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Download Parent/Guardian Name: Address: City: State: Zip: Primary Contact Number: Email : Secondary Contact Number: Email: Please select all sessions that your child ...
Technology for chemical cleaning of steam generators at fossil stations was developed during the latter half of the 20th century. Cleaning solvents and processes were developed for application to conventional boilers. The new fleet of combined cycle
DCR /
/ CO / For internal use only
/ DS
TCEQ - DRY CLEANING DROP STATION REGISTRATION FORM Please mail completed form to: Dry Cleaning Registration Team (MC-138) Texas Commission on Environmental Quality P. O. Box 13087 Austin, Texas 78711-3087 (512) 239-2160 and fax # (512) 239-3398
Texas Commission on Environmental Quality
For Use In Texas
TCEQ Account No. : Federal Tax ID No. : Taxpayer ID No. :
TCEQ rules (Title 30 TAC § 337) state that annual renewal registration forms are due by August 1st of each year For each facility, complete a separate Dry Cleaning Facility Registration Form (Form# 20092) Section 1. Reason For Filing the Form (Check all that apply) 1 4 5 6
Initial Registration 2 Renewal Registration 3 Ownership Change (indicate effective date) ____/_____/_____ No longer a drop station (Indicate effective date of the closing of the drop station) _____/_____/_____ Change from facility to drop station (Indicate effective date of change) ____/_____/_____ Amendment of: Owner Information 9 Drop Station Information Real Property Owner 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:
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
3. Drop Station Information
Regulated Entity No.: RN __________________
Drop Station 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 Code:________ Latitude: Degrees _______Minutes _______Seconds ________ Longitude: Degrees ________Minutes________ Seconds _________
Please indicate your gross receipts (this includes all sources of income from this location, including laundry receipts) for the last consecutive 12 months reported to the Comptroller: $150,000 or less more than $150,000
This number should be the same as the ATotal 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)
Date operations began 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 drop station.
For each facility, complete a separate Dry Cleaning Facility Registration Form (Form# 20092) TCEQ-20207(Rev 8/30/2006)
CN # _________________________________
RN # ____________________________________
Section 4. Real Property Owner (if different from drop station owner) Name: ______________________________________ Mailing Address:_____________________________________________________________________ City:____________________________State_______________Zip_________________ Contact Person:___________________________________ Phone No: ______/_____-_____ 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. Related Dry Cleaning Facilities (If there are dry cleaning facilities associated with this drop station, list them below) Name
Address
RN #
1. 2. 3. Section 7. 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/Legal Representative____________________________
Date _______/ _______/________
Print Name of Owner/Legal Representative________________________________Title__________________________
*Please complete a separate form for each dry cleaning drop station.*
For each facility, complete a separate Dry Cleaning Facility Registration Form (Form# 20092) If you have any questions on how to fill out this form or about the Dry Cleaner program, please contact us at 512/239-2160. Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in their information corrected. To review such information, contact us at 512-239-2160.
