DERR-2024-009122

State of Utah
Division of Environmental Response and Remediation UST Utah Third- Party B Inspector Registration Form

Facility ID Facility Name Facility Address Primary B

Applicant Name: _____________________________
Work Address: Street, City, State, Zip:
___________________________________________
Contact Number: _____________________________
Email Address: _______________________________
Employer/Contractor Name: ______________________
Employer Address: Street, City, State, Zip:
______________________________________________
Contact Number: _______________________________
Employer Contact: ______________________________
Operator Training Date:____________ Organization Providing Training____________________________________________
Utah UST Installer or Utah UST Tester Certification #__________________________OR Inspector Date:__________________ Each UST facility must have three classes of operators (A, B, and C) to perform specific duties and help ensure that UST systems remain in compliance and protects human health and the environment. Please list all facilities you may be responsible for as B operator. (List additional facilities on back of this form). Each facility should have ONLY ONE “Primary B” Operator. Do not check “Primary B” if you are a backup. If you are the Primary A or Primary B Operator, you will be required to be re-trained if any of
the listed facilities are found to be out of compliance under UAC R311-201-12(k).
I hereby certify that the above information is true and that I have read the UST Operator Training and Registration requirements for Class
A and B Operators in the Utah Administrative Code R311-201-12. I understand that submission of false or misleading information on this
application may result in rejection of the registration.

Signature_______________________________________________________________ Date:____________________
For State Use Only
Registration # OB__________ Expiration Date____________
Training and Citizenship Form Confirmed: Yes or No
Date Passed__________ Date Fee Processed_______________ Order #____________
Division of Environmental Response and
Remediation
195 North 1950 West
P.O. Box 144840
Salt Lake City, Utah 84114-4840
[phone]
Applicant Type: Initial $100.00 or Renewal Registration $50.00
Step 1: Fill out application completely. Incomplete applications are not accepted.
Step 2: Attach notarized citizenship form, copy of driver’s license and training certificate. (Initial Applicant Only)
Step 3: Attach Utah Tank Tester Certification (see Tester application for registration details) or Utah Tank Installer Certification (see Installer application for registration details) or attach documentation of Inspector Training (Remover Training Certificate & Installer Training Certificate) and General Liability Insurance with limits of $250,000.00.
Step 4: Pay registration fee online at DERRpay.utah.gov and print receipt to attach to application.
Step 5: Email application, supporting documents and receipt to [e-mail] or mail to DERR, P.O. Box 144840, Salt Lake City, UT 84114-4840. Application and payment must be submitted 5 days prior to exam date.
Step 6: Choose exam date from available dates sent by [e-mail] after receipt of application. Testing is offered first Tuesday of each month at 9:00 AM or the third Tuesday of each month at 2:00 PM.

Applicant Name: _________________________________ Company Name: ____________________________________

Facility ID Facility Name Facility Address Primary B

Proof of Citizenship
Applicants for this certification or registration are required to provide proof
of citizenship. Please complete the following:
 Fill out this form.
 Attach a copy of your government issued photo ID.
 Have this document notarized.
OR
 Check here to indicate you have previously submitted a citizenship form to the DERR.
Utah Department of Environmental Quality
Certification Pursuant to UCA 63G-12-104
I, _____________________________________, hereby certify under penalty of perjury that I am:
Full Name
 A United States citizen. (must have copy of government issued photo ID attached)
OR
 A qualified alien as defined in 8 USC, Sec. 1641, and lawfully present in the United States.
Alien ID #: __________________
Dated this ____________ day of ________________________, 20____.
Applicant’s Full Name: _______________________________________
Address: ___________________________________________________
__________________________________________________________
Applicant’s Signature: _____________________________________________________
SUBSCRIBED AND SWORN to before me this ______ day of ________________, 20____.
________________________________
NOTARY PUBLIC
My commission expires: _____________
Division of Environmental Response and
Remediation 195 North 1950 West
P.O. Box 144830
Salt Lake City, Utah 84114-4830
Phone: ( 801) 536-4100
Government Issued
PHOTO ID
(Place copy here)
(Driver’s License, Passport, Permanent
Resident Card, etc.)
(May attach copy)