APPLICATION FOR UST SERVICE PROVIDER CERTIFICATION …static.azdeq.gov/forms/ust_service_provider.pdf · APPLICATION FOR UST SERVICE PROVIDER CERTIFICATION . 1 . Applicant Information.

APPLICATION FOR UST SERVICE PROVIDER CERTIFICATION

1 Applicant Information 2 Employer Information

Applicant Name

Mailing Address

City State ZIP Code

Mobile Phone # Email Address

3 Category of Certification*(A.A.C. R18-12-806(A) requires only one category per application)

Installation and Retrofit (INR) Decommissioning (D)

Tightness Testing (T) Cathodic Protection Testing (CP) Interior Lining (IL)

4 Additional Requirements Two – One Inch by One Inch Color Photographs (required for each category) Copy of Current ICC Certification (required for INR, D and T) Copy of Current NACE or ICC Certification (required for CP) Copies of Manufacturer Certification (required for T and IL) 3rd Party Certification for a Lining Material to Meet API Standard 1631 (required for IL)

Applicable MSDS for Lining Material (required for IL)

5 Certification Statement I certify that the information submitted on and with this Application is true, accurate and complete

Signature of Applicant Date of Signature

*For more information regarding the application process in general or any additional requirements that may apply, please refer to the Underground Storage Tank Service Provider Program fact sheets - General Information and Interior Lining Certification.

Revised Sep 2016

AZ DEPT OF ENVIRONMENTAL QUALITY UST-LUST SECTION

1110 WEST WASHINGTON STREET PHOENIX, ARIZONA 85007-2935 602.771.7273 or [email protected]

TOLL FREE IN AZ 800.234.5677 EXT 7717273

Employer Name

Mailing Address

City State ZIP Code

Main Phone # Email Address