Form UST/POI "Standard Proof of Identity" - Massachusetts

What Is Form UST/POI?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Massachusetts 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 UST/POI by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download Form UST/POI "Standard Proof of Identity" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Air & Waste
Underground Storage Tank (UST) Program
UST/POI – Standard Proof of Identity
Instructions
Anyone electronically submitting registration, third-party inspection or compliance certification forms on behalf of a UST System
Owner or Operator Entity must complete this Proof of Identity form, documenting his or her authority to electronically sign them.
1.
If you have not done so yet, create a
UST Data Management/Online Filing System
User Account.
2.
Complete and print this form. Note: When filling it out on the computer, use only the Tab key to move your cursor - do not
use the Return (or Enter) key.
3.
Provide a handwritten signature and have it witnessed by a Notary Public.
4.
Mail the completed and signed form to:
MassDEP UST Program
Data Management
One Winter Street, 6th Floor
Boston, MA 02108
A. Legal Name of Owner or Operator Entity
2. This Entity is the
Owner
Operator
1. Entity Name
*Do not enter a Social Security Number here. If you do not have an
FEIN, contact
dep.ust@state.ma.us
for assistance.
3. Federal Employee Identification Number (FEIN)*
4. Mailing Address
5. City/Town
6. State
7. Zip Code
B. Owner or Operator Signatory Certification Statement
“I certify under penalty of law that I have personally
1. Print Owner/Operator Signatory Name
examined and am familiar with the information submitted
in this document and all attachments, and that, based on
my inquiry of those individuals immediately responsible for
2. Signature
obtaining the information, I believe that the information is
true, accurate, and complete. I am aware that there are
3. Date Signed (MM/DD/YYYY)
significant penalties for submitting false information,
including possible fines and imprisonment.”
4. Telephone Number
5. Email Address
Source of Authority to Electronically Sign Documents
6.
(check only one box):
If a Partnership:
If a Corporation or Non-Profit Corporation:
g.
General Partner (if authorized to contractually bind the
a.
President
partnership)
b.
Secretary
If a Sole Proprietorship:
c.
Treasurer
h.
Proprietor
d.
Vice President (if authorized to contractually bind the
corporation)
If a Municipality or Public Agency:
e.
Employee of the Corporation (if authorized to contractually
bind the corporation)
i.
Principal Executive Officer or Ranking Elected Official
(if authorized to contractually bind the municipality or public
If a Limited Liability Company (LLC):
agency)
f.
Person authorized to contractually bind the company
If a Trust:
k.
Trustee or Other Person authorized to contractually bind the
trust
UST/POI – 1/16
Standard Proof of Identity • Page 1 of 2
Massachusetts Department of Environmental Protection
Bureau of Air & Waste
Underground Storage Tank (UST) Program
UST/POI – Standard Proof of Identity
Instructions
Anyone electronically submitting registration, third-party inspection or compliance certification forms on behalf of a UST System
Owner or Operator Entity must complete this Proof of Identity form, documenting his or her authority to electronically sign them.
1.
If you have not done so yet, create a
UST Data Management/Online Filing System
User Account.
2.
Complete and print this form. Note: When filling it out on the computer, use only the Tab key to move your cursor - do not
use the Return (or Enter) key.
3.
Provide a handwritten signature and have it witnessed by a Notary Public.
4.
Mail the completed and signed form to:
MassDEP UST Program
Data Management
One Winter Street, 6th Floor
Boston, MA 02108
A. Legal Name of Owner or Operator Entity
2. This Entity is the
Owner
Operator
1. Entity Name
*Do not enter a Social Security Number here. If you do not have an
FEIN, contact
dep.ust@state.ma.us
for assistance.
3. Federal Employee Identification Number (FEIN)*
4. Mailing Address
5. City/Town
6. State
7. Zip Code
B. Owner or Operator Signatory Certification Statement
“I certify under penalty of law that I have personally
1. Print Owner/Operator Signatory Name
examined and am familiar with the information submitted
in this document and all attachments, and that, based on
my inquiry of those individuals immediately responsible for
2. Signature
obtaining the information, I believe that the information is
true, accurate, and complete. I am aware that there are
3. Date Signed (MM/DD/YYYY)
significant penalties for submitting false information,
including possible fines and imprisonment.”
4. Telephone Number
5. Email Address
Source of Authority to Electronically Sign Documents
6.
(check only one box):
If a Partnership:
If a Corporation or Non-Profit Corporation:
g.
General Partner (if authorized to contractually bind the
a.
President
partnership)
b.
Secretary
If a Sole Proprietorship:
c.
Treasurer
h.
Proprietor
d.
Vice President (if authorized to contractually bind the
corporation)
If a Municipality or Public Agency:
e.
Employee of the Corporation (if authorized to contractually
bind the corporation)
i.
Principal Executive Officer or Ranking Elected Official
(if authorized to contractually bind the municipality or public
If a Limited Liability Company (LLC):
agency)
f.
Person authorized to contractually bind the company
If a Trust:
k.
Trustee or Other Person authorized to contractually bind the
trust
UST/POI – 1/16
Standard Proof of Identity • Page 1 of 2
Massachusetts Department of Environmental Protection
Bureau of Air & Waste
Underground Storage Tank (UST) Program
UST/POI – Standard Proof of Identity
C. Witness Statement
– Must be Completed by a Notary Public
“On this date, the
Notary Seal:
1. State
individual named above
personally appeared
2. County
before me. S/he is to me
known to be the person
described in, and who
3. Notary Public Name (Printed)
executed, the foregoing
instrument, and
4. Notary Public Signature
acknowledged that s/he
executed the same as
5. Date Signed (MM/DD/YYYY)
her/his free act and deed.”
6. Date My Commission Expires (MM/DD/YYYY)
UST/POI – 1/16
Standard Proof of Identity • Page 2 of 2
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