Department of Natural Resources and Environmental Control
Tank Management Section
1351 Underground Storage Tank Systems
DNREC UST Facility ID# ________-______________________
Type of Financial Assurance Mechanism ___________________________________
Is this mechanism being used in combination with any other FR mechanism? Yes* No
*If "Yes" note additional FR mechanism ___________________________________
Owner City Owner State Owner Zip
______________________________________________________________________
Tank ID# __________ (from UST registration form)
Tank capacity ________________________
Regulated substance stored ____________________________________
______________________________________________________________________
Tank ID# __________ (from UST registration form)
Tank capacity ________________________
Regulated substance stored ___________________________________
______________________________________________________________________
Tank ID# __________ (from UST registration form)
Tank capacity ________________________
Regulated substance stored __________________________________
______________________________________________________________________