Form 2630-PM-BECB0506C Attachment A "Storage Tank Installer and Inspector Application" - Pennsylvania

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This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2012;
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2630-PM-BECB0506c 4/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
STORAGE TANK INSTALLER AND INSPECTOR APPLICATION ATTACHMENT A
IMPORTANT – PLEASE READ
You must include this Attachment A with your Application for Installer/Inspector Certification. Although your
Application may list more than one certification category, you must complete a separate Attachment A for each
certification category being requested.
See the Installer / Inspector descriptions included with the Application
package for detailed descriptions of the Certification categories, and information regarding minimum qualifications
based on education, experience, training or number of completed category-specific activities.
SECTION I – APPLICANT INFORMATION
NAME OF APPLICANT
SOCIAL SECURITY NUMBER
CERTIFICATION CATEGORY BEING REQUESTED WITH THIS ATTACHMENT A
SECTION II – DOCUMENTATION OF TOTAL EXPERIENCE AND EDUCATION
Section II-a
Number of years of experience in which applicant has had substantial involvement in the activity for
which certification is being requested.
.
List employment history for the years of experience noted in II-a, above.
Company Name
From
To
Contact Name
Telephone
Section II-b
Yes
No
Is a college degree being substituted for 1-year of appropriate experience?
If
Yes, complete the following:
Name of College
Address of College or Campus Attended
Degree Earned
Major
Date
COLLEGE TRANSCRIPTS MUST BE ATTACHED
as evidence of the degree being considered
DEP USE ONLY
YEARS EXPERIENCE
ACTIVITIES COMPLETED
Required:
Provided:
Required:
Provided:
Insufficient Experience
Insufficient Number of Activities
Appropriate College Degree
Yes
No
Activities Cannot be Verified
- 1 -
2630-PM-BECB0506c 4/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
STORAGE TANK INSTALLER AND INSPECTOR APPLICATION ATTACHMENT A
IMPORTANT – PLEASE READ
You must include this Attachment A with your Application for Installer/Inspector Certification. Although your
Application may list more than one certification category, you must complete a separate Attachment A for each
certification category being requested.
See the Installer / Inspector descriptions included with the Application
package for detailed descriptions of the Certification categories, and information regarding minimum qualifications
based on education, experience, training or number of completed category-specific activities.
SECTION I – APPLICANT INFORMATION
NAME OF APPLICANT
SOCIAL SECURITY NUMBER
CERTIFICATION CATEGORY BEING REQUESTED WITH THIS ATTACHMENT A
SECTION II – DOCUMENTATION OF TOTAL EXPERIENCE AND EDUCATION
Section II-a
Number of years of experience in which applicant has had substantial involvement in the activity for
which certification is being requested.
.
List employment history for the years of experience noted in II-a, above.
Company Name
From
To
Contact Name
Telephone
Section II-b
Yes
No
Is a college degree being substituted for 1-year of appropriate experience?
If
Yes, complete the following:
Name of College
Address of College or Campus Attended
Degree Earned
Major
Date
COLLEGE TRANSCRIPTS MUST BE ATTACHED
as evidence of the degree being considered
DEP USE ONLY
YEARS EXPERIENCE
ACTIVITIES COMPLETED
Required:
Provided:
Required:
Provided:
Insufficient Experience
Insufficient Number of Activities
Appropriate College Degree
Yes
No
Activities Cannot be Verified
- 1 -
2630-PM-BECB0506c 4/2012
Applicant Name
SECTION III – DOCUMENTATION OF TOTAL NUMBER OF ACTIVITIES COMPLETED
The activity and component codes are listed below, and on page 2 of the instructions provided with the application
package.
III-a
Brief Description of Activity Completed
Type of Activity
System Component
Date Activity
Completed
Involved
Include Tank Registration Number, Capacity &
Completed
(See Codes)
(See Codes)
Substance Stored
No.
Month/Year
1 per line
1 per line
(Do not only reenter component involved)
1
2
3
4
5
6
7
8
9
10
11
12
Type of activity completed – Enter one appropriate code per line from below.
I
Installation (tank handling associated with installation)
M Modification (tank handling associated with modification)
P
Operations, service, and construction inspections or tank tightness test performed on a storage tank
system or facility
R
Removal (tank handling associated with removal)
System component involved – Enter one appropriate code per line from below.
A
Underground storage tank system
F
Aboveground manufactured metallic storage tank or storage tank system
G Aboveground nonmetallic storage tank system
H
Aboveground field constructed metallic storage tank greater than 90 foot diameter
I
Aboveground field constructed metallic storage tank less than or equal to 90 foot diameter
K
Aboveground storage tank system mechanical (piping, valves, corrosion protection, release detection,
spill and overfill prevention, etc.)
L
Aboveground storage tank system civil (foundations, field grading systems, vaults, pump supports, pipe
supports, drainage systems, etc.)
M Underground or Aboveground storage tank lining
- 2 -
2630-PM-BECB0506c 4/2012
Applicant Name
III-b. Storage Tank Facility Employer Information
Provide detailed information for each activity listed in Section III-a. The activity numbers in III-a. must correspond to
the activity numbers listed in III-b.
Applicant’s employer when work was performed
Facility where the work was completed
DEP Verified
No. 1
Company Name
Activity
Approved
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
City
Contact
State
Zip
Phone (
)
Owner Contact
Verifying Official Signature
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID .
Activity
No. 2
Company Name
Approved
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
City
Contact
State
Zip
Phone (
)
Owner Contact
Verifying Official Signature
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID .
No. 3
Company Name
Activity
Approved
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
City
Contact
State
Zip
Phone (
)
Owner Contact
Verifying Official Signature
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID .
Company Name
Activity
No. 4
Approved
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
City
Contact
State
Zip
Phone (
)
Owner Contact
Verifying Official Signature
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID .
- 3 -
2630-PM-BECB0506c 4/2012
Applicant Name
DEP Verified Applicant’s employer when work was performed
Facility where the work was completed
Approved
Activity No. 5
Company Name
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
State
Zip
Verified
City
Contact
State
Zip
Phone (
)
Verifying Official Signature
Owner Contact
Contact Phone (
)
Reported under PA certification ID
Facility Phone (
)
Approved
Activity No. 6
Company Name
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
Contact
City
State
Zip
Phone (
)
Verifying Official Signature
Owner Contact
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID
Approved
Activity No. 7
Company Name
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
State
Zip
Verified
Contact
City
State
Zip
Phone (
)
Owner Contact
Verifying Official Signature
Contact Phone (
)
Reported under PA certification ID
Facility Phone (
)
Approved
Activity No. 8
Company Name
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
Verified
State
Zip
City
Contact
State
Zip
Phone (
)
Verifying Official Signature
Owner Contact
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID
- 4 -
2630-PM-BECB0506c 4/2012
Applicant Name
DEP Verified Applicant’s employer when work was performed
Facility where the work was completed
Approved
Activity No. 9
Company Name
Owner Name
Facility Name
Address
Pa Facility I.D. #
City
Address
State
Zip
Verified
City
Contact
State
Zip
Phone (
)
Verifying Official Signature
Owner Contact
Contact Phone (
)
Facility Phone (
)
Reported under PA certification ID
No. 10
Approved
Activity
Company Name
Owner Name
Address
Facility Name
Pa Facility I.D. #
City
State
Zip
Address
Verified
Contact
City
Phone (
)
State
Zip
Verifying Official Signature
Owner Contact
Contact Phone (
)
Reported under PA certification ID
Facility Phone (
)
No. 11
Approved
Activity
Company Name
Owner Name
Address
Facility Name
Pa Facility I.D. #
City
State
Zip
Address
Verified
Contact
City
Phone (
)
State
Zip
Verifying Official Signature
Owner Contact
Contact Phone (
)
Reported under PA certification ID
Facility Phone (
)
No. 12
Approved
Activity
Company Name
Owner Name
Address
Facility Name
City
Pa Facility I.D. #
State
Zip
Address
Verified
Contact
City
Phone (
)
State
Zip
Verifying Official Signature
Owner Contact
Contact Phone (
)
Reported under PA certification ID
Facility Phone (
)
- 5 -