Form 2630-PM-BEC0506 "Storage Tank Installer and Inspector Certification Application" - Pennsylvania

What Is Form 2630-PM-BEC0506?

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 January 1, 2019;
  • The latest edition provided by the Pennsylvania Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 2630-PM-BEC0506 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Environmental Protection.

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Download Form 2630-PM-BEC0506 "Storage Tank Installer and Inspector Certification Application" - Pennsylvania

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2630-PM-BECB0506
Rev. 1/2019
COMMONWEALTH OF PENNSYLVANIA
Certification Application
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
GE TANK INSTALLER AND INSPECTOR CERTIFICATION APPLICATION
STORA
(Please see application instructions document for important information)
OFFICIAL USE ONLY
D A T E
Application #
Appl. Appr.
Appl.
Client ID #
Denied
Employer ID #
Master Auth. #
Auth. ID#
Date Rec’d
SECTION I – APPLICANT INFORMATION
Name
SSN
Birthdate
Last
First
MI
MM/DD/YYYY
Home Address
City
State
Zip +4
Municipality
County
(City, Boro, Twp)
Primary Phone (
)
Additional Phone (
)
Email Address
DEP Client ID #
DEP Certification ID #
SECTION II – APPLICATION TYPE
FIRST certification request
MODIFY/ADD certification
RENEW certification
Is this application being submitted in response to a Letter of Denial under Chapter 245?
Yes
No
Has an enforcement action (NOV, suspension, revocation, order, etc.) pursuant to the Storage Tank Act ever been
taken against the applicant?
Yes
No
If Yes, explain:
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2630-PM-BECB0506
Rev. 1/2019
COMMONWEALTH OF PENNSYLVANIA
Certification Application
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
GE TANK INSTALLER AND INSPECTOR CERTIFICATION APPLICATION
STORA
(Please see application instructions document for important information)
OFFICIAL USE ONLY
D A T E
Application #
Appl. Appr.
Appl.
Client ID #
Denied
Employer ID #
Master Auth. #
Auth. ID#
Date Rec’d
SECTION I – APPLICANT INFORMATION
Name
SSN
Birthdate
Last
First
MI
MM/DD/YYYY
Home Address
City
State
Zip +4
Municipality
County
(City, Boro, Twp)
Primary Phone (
)
Additional Phone (
)
Email Address
DEP Client ID #
DEP Certification ID #
SECTION II – APPLICATION TYPE
FIRST certification request
MODIFY/ADD certification
RENEW certification
Is this application being submitted in response to a Letter of Denial under Chapter 245?
Yes
No
Has an enforcement action (NOV, suspension, revocation, order, etc.) pursuant to the Storage Tank Act ever been
taken against the applicant?
Yes
No
If Yes, explain:
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2630-PM-BECB0506
Rev. 1/2019
Certification Application
SECTION III – CURRENT EMPLOYER INFORMATION (If more than one employer, attach additional pages)
Hire Date
Employer’s Federal Tax ID # (EIN)
Employer’s DEP Client ID #
Employer’s Certification #
Name
Company Type Code
Street Address
City
State
Zip +4
Municipality
County
(City, Boro, Twp)
Telephone (
)
-
Fax (
)
-
Company Contact Person
Email Address
SECTION IV – CORRESPONDENCE ADDRESS (Where study guides, certificates, etc. are sent)
Applicant Address
Employer’s Address
If more than one employer and choosing to have correspondence delivered to your employer’s address, please
provide the employer’s name:
SECTION V – CERTIFICATION CATEGORIES
(A)
INITIAL Category Approval (First time applicant, not a renewal)
Check the appropriate boxes in the INITIAL column for each category in which you are applying. Please download
the Initial Qualifications sheet from our website,
www.dep.pa.gov
to verify you meet all the qualification
requirements for the category(ies) for which you are applying. Please note: Applicant must complete a
separate Attachment A for each certification category requested.
If technical training, a manufacturer’s certification, or an inspector certification is required for the requested
category, please submit a copy of the appropriate certificate with this application. The certificate must specifically
name the applicant.
(B)
RENEWAL Options
Retest – Retaking and passing the category-specific examination may be used for renewal.
Training – Attend, and successfully complete, a Department-approved category-specific training course
instead of retesting. Successful completion means attendance at all course sessions and attainment of the
minimum passing grade for the course. Please submit a copy of the course completion certificate with this
application.
UTT and TL candidates should also check the box under Training and submit a copy of the manufacturer’s training
certificate or letter with this application. The certificate or letter must specifically name the applicant.
Individuals holding IUM, IAM, or IAF certification are trained by DEP staff. A training record for inspectors is
maintained by the Department so no training certificate needs to be submitted.
(C)
DELETIONS
If the applicant wants to withdraw a certification category, indicate which category is to be removed by checking
the box adjacent to that category in the Delete column.
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2630-PM-BECB0506
Rev. 1/2019
Certification Application
Renewal
Initial
Retest
Training
Delete
INSTALLER CATEGORIES
Underground
UMX
UMI
UMR
UTT
Aboveground
AMMX
AMNX
AMR
AFMX
AFR
AMEX
ACVL
Underground/Aboveground
TL
INSPECTOR CATEGORIES
Underground
IUM
Aboveground
IAM
IAF
RENEWAL APPLICANTS – Date of last Administrative or Inspector Training session attended:
SECTION VI – APPLICANT’S CERTIFYING STATEMENT
I certify under penalty of law as provided in 18 PA C.S.A. §4904 (relating to unsworn falsification to authorities),
that I am the applicant herein named, that I have received the safety training as provided for under §245.111(h) of the
regulations, and that the information I have provided on this Application for Certification is true, accurate, and complete
to the best of my knowledge and belief.
/
/
Signature of the Applicant
Date
SECTION VII – EMPLOYER’S CERTIFYING STATEMENT
I certify under penalty of law as provided in 18 PA C.S.A. §4904 (relating to unsworn falsification to authorities),
that I am an officer of the applicant’s employer. The applicant herein named has been provided with adequate safety
training as provided for under §245.111(h) of the regulations. I further certify that the information provided on this
Application for Certification is true, accurate, and complete to the best of my knowledge and belief.
/
/
Signature & Title of Company Official
Date
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2630-PM-BECB0506
Rev. 1/2019
Certification Application
APPLICANT’S CHECKLIST
(For your records)
INITIAL REQUEST FOR CERTIFICATION IN A CATEGORY
This Application, signed by the applicant and the employer
Attachment A (If required)
A Copy of the Applicable Training Certificate(s)
REQUEST FOR RENEWAL OF CERTIFICATION IN A CATEGORY
This Application, signed by the applicant and the employer
Check the RETEST box if renewing by examination, or
Check the TRAINING box if renewing by training or equipment manufacturer’s certification.
IF YOU ARE RENEWING YOUR CERTIFICATION
Please record the date you last attended administrative training
I last attended Administrative Training on
, 20
.
I am not required to attend Administrative Training because I am certified as an INSPECTOR ONLY and I DO
NOT hold a tank handling certification of any kind.
The Department reserves the right to request additional information necessary to determine whether the issuance of a
certification conforms to Act 32 and Chapter 245.
The applicant should retain a copy of the application and all attachments. Submit the application and copies of the
applicable training certificates via mail or email to:
MAILING ADDRESS:
EMAIL ADDRESS:
Pennsylvania Department of Environmental Protection
tanks@pa.gov
Bureau of Environmental Cleanup and Brownfields
Division of Storage Tanks
PO Box 8762
Harrisburg, PA 17105-8762
If you have questions, please call Customer Service at:
717-772-5599
or
1-800-42-TANKS (In PA)
Additional information may be obtained by calling Storage Tanks customer service at the above numbers, or by visiting
www.dep.pa.gov, Search: Storage Tanks.
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