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Home My WebLink AboutDERR-2024-007440 Utah Department of Environmental Quality Division of Environmental Response and Remediation Petroleum Storage Tank Loan Program Loan Application Applicant Name Date of Birth SSN Phone Address City St. Zip Rent Own Yrs? marital status Previous Address City St. Zip Rent Own Yrs? no. dependents Name and address of Yrs. worked at present job Employer (if not the facility) Co-applicant Name Date of Birth SSN Phone Address City St. Zip Rent Own Yrs? marital status Previous Address City St. Zip Rent Own Yrs? no. dependents Name and address of Yrs. worked at present job Employer (if not the facility) Business Name Phone Address City St. Zip Fed. Tax Id/SSN Facility and Tank Information Type of Ownership Name ID# Sole Co-owner Address City St. Zip Partnership Corporation Facility Mortgage with Incorporated in (state): Tank Information Use of Loan Proceeds Tank # Spill Prevention Overfill Prevention Tank Lining Age Cathodic Protection: Sacrificial Anode Impressed Current Capacity Leak Detection System Type of System Substance Stored Replace Tanks Permanently Close Tanks Certified Contractors to be used: Installer Cert. # Phone Remover Cert. # Phone Sampler Cert. # Phone Tester Cert. # Phone Other UST facilities you own: Name Facility ID# Address City St. Zip No. of: USTs ASTs Name Facility ID# Address City St. Zip No. of: USTs ASTs Circle Yes or No for each of the following: Yes No Are all UST registration fees paid for all facilities you own? Yes No Are all Petroleum Storage Tank fund fees paid for all facilities you own? Yes No Do all facilities you own have a current Certificate of Compliance? Yes No Are all your facilities currently in compliance with all UST rules and regulations? Yes No I have less than $1,000,000 annual gross income and fewer than 5 full-time employee equivalents. The facility is not owned or operated by anyone not meeting these criteria. Yes No My income is derived solely from operations at UST facilities. Yes No I own or operate no more than two facilities. Yes No The facility is located in a US Census Bureau population unit containing fewer than 5,000 people. Yes No There are no more than three operating retail motor fuel outlets within 15 road miles in all directions. Yes No Loan proceeds will be used solely for replacing or upgrading USTs. Yes No All USTs at the facility are greater than 15 years old. miles Number of miles to the nearest operating retail outlet selling motor fuel. Please answer the following: Applicant Co-applicant Are there any outstanding judgments against you? Yes No Yes No If yes, explain on attached sheet. Have you declared bankruptcy within the past 7 years? Yes No Yes No If yes, when? Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? Yes No Yes No If yes, explain on attached sheet. Are you and/or your facility party to a lawsuit? Yes No Yes No If yes, explain on attached sheet. Are you obligated to pay alimony, child support, or separate maintenance? Yes No Yes No If yes, explain on attached sheet. Are you a co-maker or endorser on a note? Yes No Yes No If yes, explain on attached sheet. Are you a US citizen? Yes No Yes No If no, are you a resident alien? Yes No Yes No If no, are you a non-resident alien? Yes No Yes No Loan Information: Loan amount: (Loan Amount may be no more than $150,000 per facility, $50,000 per tank, or 80% of the total cost of the project) Loan repayment term desired: Monthly payment desired: Proposed security for loans greater than $30,000: The Director may approve an initial loan disbursement, to be made after loan closing and before the work is done. The disbursement may be for the lesser of 40% of the approved loan amount or the amount the contractor requires as an initial payment before work is done. Enter the amount of the initial disbursement requested: Brief Description of plans for the facility Please include with your application:  Detailed construction work plan and budget. This can be in bid form by a contractor.  Balance sheet (may use form or a separate document)  Personal and corporation (if applicable) federal and state tax returns for the last two years. I am willing to: 1) Comply with all applicable laws and work with designated technical personnel as assigned by the Director in preparation of proposed Petroleum Storage Tank Loan Application and other documents as needed. 2) Allow continued monitoring and evaluation of work plan to ensure proper usage of loan funds. 3) Submit a detailed financial statement for review of my credit worthiness and repayment ability. I/we certify under penalty of law that the information I/we have provided in this application is true and correct, to the best of my/our knowledge. I/we understand that you will retain this application whether or not it is approved. You are authorized to check my/our credit and facility history and to answer questions about your credit experience with me/us. I/we have read and understand the application form and agree to provide additional information which may be legally required to determine creditworthiness. Any and all costs to complete any of the required information are my responsibility. (Note: Falsification of credit information may be a federal offense and may result in exemption from discharge in the event a petition for bankruptcy is filed). Applicant (print) Co-applicant (print) Applicant Signature Date Signed Co-applicant Signature Date Signed application.docx 07/14/16 Utah Department of Environmental Quality Division of Environmental Response and Remediation Petroleum Storage Tank Loan Program Balance Sheet Statement for: as of: Assets Liabilities 1. Cash on hand and in banks $ Accounts Payable (Schedule 7d) $ 2. Accounts and Notes receivable (Schedule 1) Notes Payable- Secured (Schedule 7b) 3. Inventory (Schedule 2) Notes Payable- Unsecured (Schedule 7c) 4. Other Current Assets: Taxes 5. Other Current Debts: 6. 7. 8. Life Insurance, Cash Surrender Value 9. Stocks and Bonds (Schedule 3) 10. Total Current Assets: $ Judgments 11. Equipment (Schedule 4) $ Total Current Liabilities: $ 12. Vehicles (Schedule 5) Real Estate Mortgages Payable (Schedule 7a) $ 13. Real Estate (Schedule 6) Equipment (Schedule 7b) 14. Long-term Portion of Notes Receivable Vehicles (Schedule 7b) 15. Other Assets: Long-term Notes Payable (Schedule 7e) 16. Other Liabilities: 17. 18. Total Long-term Liabilities: $ 19. Total All Liabilities: $ 20. Total Long-term Assets: $ 21. Total Net Worth (If a corporation, complete Schedule 10.): $ 22. Total Assets: $ Total Liabilities and Net Worth: $ Supplemental Schedules. If additional space is needed, attach sheet(s) No. 1 Accounts and Notes Receivable Name and address of Debtor Payment Date Date of Debt Description of Security Held Amt. Owed Total Value: $ No. 2 Inventory Description Value Description Value Total Value: $ No. 3 Stocks and Bonds Face Value (Bonds) or No. Shares (Stock) Name of Corporation Cost Income Received Last Year To Whom Pledged Present Market Value Total Value: $ No. 4 Equipment Description Purchase Price Appraised Value VIN Number Value Total Value: $ No. 5 Vehicles Description Purchase Price Appraised Value VIN Number Value Total Value: $ No. 6 Real Estate Legal Description/ Address Size of Parcel Appraised Value Total Value: $ No. 7 Mortgages, Notes, and Accounts Payable Name of Creditor Description of Security Total Amount Owed Payment Date Due Current Year Years Remaining 7a Real Estate Mortgages Payable 7b Notes Payable (Secured) 7c Notes Payable (Unsecured) 7d Accounts Payable 7e Long-term Notes Payable The statements made in this Balance Sheet are for the purposes of inducing the Director to grant the credit requested. I/we certify under penalty of law that the information I/we have provided in this Balance Sheet is true and correct, to the best of my/our knowledge. I/we understand that you will retain this statement whether or not credit is approved. You may verify all information given in connection with this statement, employment and income history and answer questions about your credit experience with me/us. Applicant (print) Co-applicant (print) Applicant Signature Date Signed Co-applicant Signature Date Signed balancesheet.docx 07/29/14