DERR-2024-009127

State of Utah
Division of Environmental Response and Remediation Utah UST Installer Certification Application

Applicant Type: Initial or Renewal Certification
Type of Installer: General Technician Cathodic Protection Tank Lining AST Technician
Step 1: Fill out application completely. Incomplete applications are not accepted.
Step 2: Attach notarized citizenship form, copy of driver’s license and Installer training certificate and installation experience. (Initial Applicant Only)
Step 3: Attach Financial Assurance with limits of $250,000.00.
Step 4: Pay $275.00 certification 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______________________________
Work Address: Street, City, State, Zip
___________________________________________
Contact Number: ____________________________
Email Address__________________________
Employer/Contractor Name ____________________
Employer Address: Street, City, State, Zip:
____________________________________________
Contact Number: ______________________________
Employer Contact: ____________________________

Installer Training Date:______________ Organization Providing Training__________________________________________
UST INSTALLATION EXPERIENCE Please attach a letter, signed by your employer or immediate supervisor, detailing your UST installation experience. The letter must indicate that the applicant has actively participated in three UST installations. Include dates, locations, name(s), and phone number(s) supervising the UST installations. The application will not be accepted without this letter.

I hereby certify that the above information is true and that I have read the certification requirements for the UST Installer 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
Registration # TL__________ 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]
FINANCIAL ASSURANCE Complete the Financial Assurance Agreement form on the back page. A current certificate of insurance or other approved form of Financial Assurance must be attached to this application. The application WILL NOT be accepted
without documentation of Financial Assurance.
EMPLOYERS AGREEMENT I hereby represent that the applicant named above is an employee and agree that as the employer of the applicant, I will satisfy the Financial Assurance requirements of R311-201-4 by one or more of the alternative Financial Assurance mechanisms described herein so long as the applicant is in my employ.
Employers Signature: _________________________________________________ Date: ____________

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)