Free 48079.PDF - Indiana

NOTICE OF INTENT TO PURCHASE UST AND REINSTATE ELIGIBILITY
State Form 48079 (R / 12-00)

INSTRUCTIONS:

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To be completed by current owner. If the scheduled purchase date is postponed, you must resubmit this form at least sixty (60) days prior to the revised planned purchase date. This form will be destroyed, and the information will be invalid ninety (90) days after the scheduled date of closing unless the closing occurs. SITE INFORMATION

Name

Facility ID number

Address (number and street or rural route)

City, state and ZIP code

Number of registered UST tanks at this location

LUST incident numbers attributed to this site

CURRENT OWNER INFORMATION Name of current owner Current owner ID number

Address of current owner (number and street or rural route)

City, state and ZIP code

Signature of current owner

Date signed (month, day, year)

NEW OWNER INFORMATION Name of new owner New owner ID number

Address (number and street or rural route)

Federal ID or Social Security number (if applicable)

City, state and ZIP code

Scheduled date of closing (month, day, year)

Scheduled closing date must be at least sixty (60) days after the Indiana Department of Environmental Management receives this form.

I swear or affirm under penalty of perjury, to the best of my knowledge and belief, that these statements are true and accurately represent the conditions around the site in question. I understand that pursuant to Indiana Code 13-23-14-2, IC 13-30-4-1 and IC 13-30-6-1 I may be subject to criminal and civil penalties for submitting false and/or inaccurate information on this application.
Signature of new owner Date signed (month, day, year)

DISTRIBUTION:

White - Agency;

Canary - New Owner;

Pink - Current Owner