Draft

Department of Environmental Protection

2600 Blair Stone Road ♦ Tallahassee, Florida 32399-2400

General Facility Information Facility Name: DEP Facility ID Number: Street Address (physical location): County: Owner Name:

Facility Telephone:___________________ Owner Telephone:

Owner Address:

Storage Tank System Information Number of Tanks Installed: Number of Tanks Removed: Date Work Initiated: Date Work Completed: Tank(s) Manufactured by: Description of Work Completed

Certification I hereby certify and attest that I am familiar with the facility that is registered with the Florida Department of Environmental Protection; that to the best of my knowledge and belief, the storage tank system installation, replacement or removal at this facility was conducted in accordance with Chapter 489, Florida Statutes, Section 376.303, Florida Statutes, and Chapter 62-761, F.A.C., and its adopted reference requirements and documents for underground storage tank systems.

(Type or Print)

Certified Pollutant Storage System Contractor Name PSSC Number (Pollutant Storage System Contractor License #)

Certified Pollutant Storage System Contractor Signature Date

Field Supervisor’s Name Date

The owner or operator of the facility must register a new storage tank system with the Department and submit to tankregistration@floridadep.gov, prior to installation, see Rule 62-761.400, F.A.C. The installer must submit this form to the *County no more than 21 days after the completion of installation, replacement, or 21 days after removal of a storage tank system and system components in accordance with Rule 62-761.400, F.A.C.

*County means a locally administered governmental program under contract with the Department to perform compliance verification activities at facilities with storage tank systems.

DEP Form: 62-761.900(5)

Form Title: Certified Contractors Form

Effective Date: Draft 2018

Incorporated in Rule 62-761.400, F.A.C.

Underground Storage System Installation and Removal Form for Certified Contractors Pollutant Storage Systems Contractor as defined in Section 489.105, Florida Statutes [Certified Contractor as defined in Rule 62-761.200, Florida Administrative Code (F.A.C.)] shall use this form to certify that the installation, replacement or removal of the underground storage tank system(s) located at the address listed below was performed in accordance with the Reference Guidelines in 62-761.210, F.A.C. This includes system components in contact with soil, such as dispenser sumps li-------ners, piping sumps, and spill containment systems.