Petroleum Storage Tank Registration Page 1
MoDNR Logo MISSOURI DEPARTMENT OF NATURAL RESOURCES
HAZARDOUS WASTE PROGRAM
FACILITY ID NUMBER

ST MO
PETROLEUM STORAGE TANK REGISTRATION
Return completed from to:
Missouri Department of Natural Resources
Hazardous Waste Program
P.O. Box 176
Jefferson City, MO 65102

Help Page
FOR AGENCY USE ONLY
CHECK NUMBER
 		 DATE RECEIVED
 
Check Amount
 
Owner Number
 
DATA ENTRY BY
 		 DATE
 
OWNER INFORMATION
TANK OWNER NAME (CORPORATION, INDIVIDUAL, AGENCY, ETC.)
ADDRESS
CITY
 STATE
 ZIP CODE
(AREA CODE)TELEPHONE NUMBER
() - 		NAME OF PROPERTY OWNER
OWNER TYPE
GOVERNMENT
FEDERAL STATE LOCAL
WHERE TO SEND REGISTRATION FEE INVOICES
(CHECK ONE)
FACILITY INFORMATION
FACILITY NAME
STREET ADDRESS (CANNOT BE A P.O. BOX)
CITY
 ZIP CODE
MAILING ADDRESS
 CITY
 STATE
 ZIP CODE
FACILITY CONTACT PERSON
FIRST NAME
 LAST NAME
JOB TITLE
 (AREA CODE)TELEPHONE NUMBER
() -
CITY
 STATE
 ZIP CODE
OTHER INFORMATION
IS THIS FACILITY CURRENTLY REGISTERED AS AN UNDERGROUND STORAGE TANK FACILITY?
FACILITY NUMBER
ST
AMEND THE CURRENT REGISTRATION?
 IF AMENDING, ARE YOU ADDING TANKS?
NUMBER OF UNDERGROUND STORAGE TANKS AT THIS FACILITY
SELECT COMPARTMENTALIZED
TANK GROUP		 TANK
CAPACITY		 TANK
STATUS		 SUBSTANCE
TYPE STORED		 SUBSTANCE
CERTIFICATION FOR NEW INSTALLATIONS
1. THE INSTALLER HAS BEEN CERTIFIED BY THE TANK AND PIPING MANUFACTURER
2. THE INSTALLATION HAS BEEN INSPECTED AND CERTIFIED BY A REGISTERED PROFESSIONAL ENGINEER
3. ALL WORK LISTED ON THE MANUFACTURER'S INSTALLATION CHECKLISTS HAS BEEN COMPLETED
4. INSTALLATION COMPANY
DATE OF INSTALLATION (MM/DD/YYYY)
OWNER CERTIFICATION
I certify that I have examined the information reported on this form. I believe this information to be true, accurate and complete.
TANK OWNER NAME
 TANK OWNER TITLE
 DATE
CERTIFICATION BY PARTY OTHER THAN TANK OWNER
I certify that I am not an owner of these tanks as defined by RSMo 319.100. However, to facilitate the registration of these tanks, I am submitting this information which I believe to be true, accurate and complete to the best of my knowledge.
NAME
 TITLE
 DATE
MO 780-1782 (10-05)