Tank Owner Authorization & Information Form

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Authorization

As owner of the below-listed property, I authorize Pollard Environmental, LLC to perform an inspection of the petroleum storage tank(s) located at the property. In the event that petroleum leakage is detected, I authorize Pollard Environmental, LLC to report the leak/release to the Virginia Department of Environmental Quality in compliance with State Water Control Law.
We (Pollard Environmental, LLC) will arrange for Miss Utility to mark public underground utilities, but they will not mark private underground utilities. We cannot be responsible for damage to underground utilities/lines that are not divulged to us by Miss Utility or the owner.
Please complete the enclosed “Tank Owner Information Sheet” so that we may perform our inspection/evaluation in the most responsible manner.

Full Legal Name of Owner(s)

If Multiple Owners, what is the Relationship?

Owner's Mailing Address:

Street Address Address Line 2 City State ZIP Code

Phone (Home)

Phone (Work)

Phone (Cell)

Contact Email

Site Address

Street Address Address Line 2 City State ZIP Code

RE Agent Name

RE Agent Phone

RE Agent Email

Include agent in all e-mail correspondence?

Yes

No

Referred to Pollard Environmental by?

Name / Title:*

Date*

Customer Signature:*

Please provide your electronic signature using the space above.