DERR-2024-009126

State of Utah
Division of Environmental Response and Remediation Utah Environmental Media Sampler Certification Application

Applicant Type: Initial or Renewal Certification
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: Pay $275.00 certification fee online at DERRpay.utah.gov and print receipt to attach to application.
Step 4: 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 5: 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. *Previous name of certification was Groundwater and Soil Sampler Certification
Applicant Name: _______________________________________________________________
Address: Street, City, State, Zip: ____________________________________________________
Contact Number: _______________________________________________________________
Email Address: _________________________________________________________________
Employer/Contractor Name: ______________________________________________________
Address: Street, City, State, Zip: ____________________________________________________
Contact Number: _______________________________________________________________
Email Address: _________________________________________________________________
Utah Environmental Media Sampler Course Date:____________ Organization Providing Training_____________________
I hereby certify that the above information is true and that I have read the certification requirements for the UST
Environmental Media (Groundwater and Soil) Sampler 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 # GS__________ 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
PO Box 144840
Salt Lake City, Utah 84114-4840
[phone]
Please do not put my employer’s name on my certificate
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)