DERR-2024-009124

State of Utah
Division of Environmental Response and Remediation Utah Consultant Initial Certification Application

Step 1: Fill out application completely. Incomplete applications are not accepted. Copy of most recent HAZWOPER certificate is required.
Step 2: Within 6 months prior to application, complete self study of the Consultant Certification Manual
Step 3: Include A signed statement or other evidence demonstrating 3 years within the past 7 years of related experience in UST Release abatement, investigation and corrective action or equivalent combination of appropriate education and experience (Resume)
Step 4: Bachelors or advanced degree in related field, professional engineering certificate, or professional geologist certificate (provide transcripts or copy of degree)
Step 5: Notarized Citizenship form with copy of driver’s license
Step 6: Pay $275.00 recertification fee (exam only)
Step 7: Email application 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 or course date.

Applicant Name: _______________________________________________________________
Address: Street City, State, Zip: ____________________________________________________
Contact Number: _______________________________________________________________
Email Address: _________________________________________________________________
Employer/Contractor Name : ______________________________________________________
Address: Street City, State, Zip: ____________________________________________________
Contact Number: _______________________________________________________________
Email Address: _________________________________________________________________
Consultant Initial Certification Fee $275.00
I hereby certify that the above information is true and that I have read the certification requirements for the PST
Consultant in the Utah Administrative Code Section R311-201. I will conform to the standards of performance as
outlined in Section R311-201-6. I understand that submittal of false or misleading information on this application
may result in revocation in the certificate.

Applicant Signature_____________________________________________________ Date:____________________
For State Use Only
Certification # CC__________ 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]
Please do not put my employer’s name on my certificate

EXPERIENCE
Begin with present position and work back 7 years, listing appropriately related experience in underground storage tank release abatement, investigation, and corrective action. Submit a signed statement or other evidence demonstrating your experience.

EXPERIENCE CONT.

EDUCATION Submit college transcripts or other evidence demonstrating your education.

TRAINING Include additional training if you wish any training to count towards meeting the education/experience requirements.

Please return completed application to Chelsea Qualls, Environmental Program Coordinator at [e-mail] OR to the following address: DEQ DERR 195 North 1950 West, 1st Floor Salt Lake City, Utah, 84116
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)