DERR-2024-009130

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

Applicant Type: Initial or Renewal Certification
Type of Testing: Tank Lines Leak Detector Cathodic Protection
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 and tank testing experience. (Initial Applicant Only). All applicants must submit a current training certificate for testing equipment for renewal and
initial certifications.
Step 3: Attach Financial Assurance with limits of $50,000.00.
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, City, State:
____________________________________________
Contact Number:_____________________________
Employer Contact: ____________________________
UST Tester Training Date:____________ Organization Providing Training______________________________________
UST PRECISION TESTER TRAINING An applicant must have successfully passed a training course conducted by the manufacturer of the UST precision testing equipment that he will be using. An applicant shall submit documentation which demonstrates the UST precision testing equipment meets performance standards of R311-202 Part 280.40(a)(3), 280.43(c), and 280.44(b) for tank and product piping tightness testing.
I hereby certify that the above information is true and that I have read the certification requirements for the UST Tester 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 # UT_________ 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 An applicant or the applicant’s employer shall have insurance, surety bonds, liquid company assets or other appropriate kinds of financial assurance. (Limits of $50,000.00)
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 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)