MoDNR Electronic Forms - Dry Cleaner Registration

	STATE OF MISSOURI
	DEPARTMENT OF NATURAL RESOURCES
	HAZARDOUS WASTE PROGRAM
	P.O. BOX 176, 1738 E ELM STREET
	JEFFERSON CITY MO, 65102-0176	Help Page
	DRY CLEANER REGISTRATION - PERCHLOROETHYLENE AND OTHER CHLORINATED SOLVENTS

YEAR OF DATA

COUNTY NAME

FIPS COUNTY NO.

PLANT NO.

I. DRY CLEANER INFORMATION

DRY CLEANER FACILITY NAME	CONTACT FIRST/LAST NAME TITLE CONTACT FIRST NAME CONTACT LAST NAME CONTACT TITLE	TELEPHONE NUMBER TELEPHONE NUMBER Area Code TELEPHONE NUMBER Exchange
STREET ADDRESS	CITY	STATE	ZIP CODE + 4 ZIP CODE + 4 Suffix
MAILING ADDRESS(IF DIFFERENT FROM ABOVE)	CITY	STATE	ZIP CODE + 4 ZIP CODE + 4 Suffix

II. BUSINESS/FACILITY OWNER INFORMATION

BUSINESS/FACILITY OWNER'S NAME BUSINESS/FACILITY OWNER'S FIRST NAME First: BUSINESS/FACILITY OWNER'S LAST NAME Last:	BUSINESS/FACILITY OWNER'S TELEPHONE NUMBER BUSINESS/FACILITY OWNER'S TELEPHONE NUMBER Area Code BUSINESS/FACILITY OWNER'S TELEPHONE NUMBER Exchange
STREET ADDRESS, P.O. BOX OR ROUTE NUMBER	FAX NUMBER FAX NUMBER Area Code FAX NUMBER Exchange
CITY	STATE	ZIP CODE + 4 ZIP CODE + 4 Suffix

III. PROPERTY'S LEGAL OWNER INFORMATION (Not business owner unless also property owner)

PROPERTY OWNER'S NAME PROPERTY OWNER'S FIRST NAME First: PROPERTY OWNER'S LAST NAME Last:	PROPERTY OWNER'S TELEPHONE NUMBER PROPERTY OWNER'S TELEPHONE NUMBER Area Code PROPERTY OWNER'S TELEPHONE NUMBER Exchange
STREET ADDRESS, P.O. BOX OR ROUTE NUMBER	Property Owner FAX NUMBER Property Owner FAX NUMBER Area Code Property Owner FAX NUMBER Exchange
CITY	STATE	ZIP CODE + 4 ZIP CODE + 4 Suffix

IV. MACHINE INFORMATION

NUMBER OF DRY TO DRY MACHINES

NUMBER OF TRANSFER MACHINES

V. SOLVENT DETAIL

SOLVENT TYPE
PERCHLOREOETHYLENE OTHER CHLORINATED SOLVENT (SPECIFY)

CALCULATE SOLVENT USE	CHLORINATED (PERC)
GALLONS ON HAND FROM PREVIOUS YEAR
GALLONS BROUGHT ON SITE DURING CALENDAR YEAR (+)
UNUSED GALLONS TRANSFERRED OFF-SITE (-)
GALLONS ON-HAND AT END OF CALENDAR YEAR (-)
TOTAL GALLONS USED DURING CALENDAR YEAR (=) (computer will calculate)

VI. CALCULATE REGISTRATION SURCHARGE. CHECK APPROPRIATE BOX AND ATTACH PAYMENT TO THIS FORM.

CALCULATED SURCHARGE, "TOTAL GALLONS USED DURING CALENDAR YEAR" FROM SECTION V ABOVE

COMPLETION AND SUBMITTAL OF THIS FORM SATISFIES THE REQUIREMENTS OF 260.915, REVISED STATUTES OF MISSOURI
THIS SURCHARGE IS REQUIRED BY 260.935, REVISED STATUTES OF MISSOURI

$ 500	0-140 GALLONS OF CHLORINATED SOLVENT.
$ 1,000	141-360 GALLONS OF CHLORINATED SOLVENT.
$ 1,500	OVER 360 GALLONS OF CHLORINATED SOLVENT.

ATTACH A CHECK FOR THE DRY CLEANER REGISTRATION SURCHARGE. DO NOT DEDUCT ANY LOCAL AIR EMISSIONS FEES FROM THIS SURCHARGE.

VII. CERTIFICATION

The undersigned hereby certifies that they have personally examined and are familiar with the information and statements contained herein and further certifies that they believe this information and statement to be true, accurate and complete. The undersigned certifies that knowingly making a false statement or misrepresenting the facts presented in this document is a violation of state law.

	PRINTED NAME AND TITLE	SIGNATURE	DATE
PERSON COMPLETING FORM
AUTHORIZED COMPANY REPRESENTATIVE

CHECK INFORMATION	CHECK AMOUNT	CHECK DATE	CHECK NO.	OFFICE USE ONLY
REGISTRATION SURCHARGE				LOGGED IN BY	DATE RECEIVED

MO 780-1745 (11-06)

DRY CLEANER REGISTRATION - PERCHLOROETHYLENE AND OTHER CHLORINATED SOLVENTS