DERR-2024-006325

FACILITY ID#
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Underground storage tank owncrs alld operators must submil by 5:00, May 25, 1994, their facility thtoughput information for thc past
calendar year io order o rcccive the proper PST fund assessment rate. A PST Fund assessment higher thao the thrcughPut b.sed rate
will be charged !o owDers and operators who fail to me€t the May 25, 1994, dcsdlille. Documentatioo verirying lhe claims made on
this form must be ma& available or submined for audit, when requested by DERR. Complete the following information lo documeot
the througbput of permleum prcducts at your facility:
Please answcr one of the loltowing no questions before complcting this fonn:
FACILITY IS ENGAGED IN PETROLEI.JM PRODUCTION, REFINING' OR MARKETING
FACILITY IS NOT ENGAGED IN PETROLEI.]M PRODUCTION, REF'INING, OR MARKETING
O
,
PETROLEUM STORACE TANK FUND
FACILITY THROUG}IPUT DECLARATION
(FrscAL YEAR 1995)
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O1VNER NAME
OWNER ADDRESS:
FACILITY NAME:
FACILITY ADDRESS:
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tPii 19$4
Received;. ,,
Div. of tnlimnm€{lfi
Ressons! &
flsmediaiionBEGIllt\In'IG INVENTORY
CIOTAL AMOUNT IN ALL REGI.JLATED TANKS ON JAN.I, 1993)
2. PIJRCHASES DI'RING THE YEAR
1 PETROLEI,JM AVAILABLE FOR USE
(ADD LINES I AND 2)GALIONS
LESS: ENDING INVENTORY
(IOTAL IN ALL REGULATED TANKS ON DEC.3I, I93)GALIONS
AMOIJNT CONSUMED DURING THE YEAR
(LINE 3 LESS LINE 4 - ALL REGI'LATED TANKS)GALI.ONS
I understand that by lalsifiing this docwnent, I could be fined $10,000 per dcy ol viobtion. I cenify wtder
pmalty of law tlwt thc above representations made by me Lre tnre ud correct.
5
Sigtrstne of owner/operator Date
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GALIPNS
CALIONS
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