Free 53148.FH11 - Indiana

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APPLICATION FOR UNDERGROUND STORAGE TANK CERTIFICATION
State Form 53148 (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 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 the Underground Storage Tank Certification is $25.00.

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

Installation or retrofitting

Cathodic Protection

Testing

Decommissioning:

Removal

Closure

Evidence is being submitted verifying the successful completion of the following (check all that apply; enclose copy of license / certificate):

The International Fire Code Institute (IFC) certification examination OR An independent testing agency examination approved by the Department of Homeland Security, Division of Fire and Building Safety OR Requesting reciprocity due to license / certification by the State of ________________________________________________.

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

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

)

Name of company (if applicable)

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

Telephone number

Cellular telephone number

E-mail address

(

)

(

)

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.
Signature Date (month, day, year)

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

Approved

Denied