Free 53150.FH11 - Indiana

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APPLICATION FOR RENEWAL OF UNDERGROUND STORAGE TANK CERTIFICATION
State Form 53150 (R2 / 3-09) Approved by State Board of Accounts, 2009

INDIANA DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE AND BUILDING SAFETY 302 West Washington Street, Room E241 Indianapolis, IN 46204 Telephone: (317) 232-2222

INSTRUCTIONS: NOTE:

Please make check payable to the Indiana Department of Homeland Security and send it to the above address.

This application for renewal must be signed by the individual and all information must be legible. Failure to file a legible, properly completed application may result in the application being rejected.
Total amount enclosed

The fee for renewal of the Underground Storage Tank Certification is $25.00.

This is a renewal application for certification in (check all that apply):

Installation or retrofitting

Cathodic Protection

Testing

Decommissioning:

Removal

Closure

GENERAL INFORMATION (please type or print legibly)
Name of applicant

Address (number and street, city, state, and ZIP code)

Telephone number

E-mail address

(

)
Telephone number

Name of company (if applicable)

(
Address of company (number and street, city, state, and ZIP code)

)

Existing Indiana certification number

I hereby certify that I am the person indicated above, that all information I have given herein is true and complete to the best of my knowledge, and that any false statement will be cause for voiding this application and /or subsequent renewal of certification.
Signature Date (month, day, year)

FOR OFFICE USE ONLY
Certificate number Date mailed (month, day, year)

Approved

Denied