FitForServiceForm_AST_504-BT_signed.pdf

ANNUAL INSPECTION CERTIFICATION

Aboveground Storage Tank

Is Fit for Service

V.7.22.2016

☐ I am a qualified individual as described in WV CSR 47‐63‐5.2 and I have performed a tank evaluation on the above AST system. I certify the tank system meets applicable standards established by WV CSR 47‐63.

☐ I am the tank owner, operator, or qualified representative of the tank owner or operator, and have performed a tank evaluation on the above AST system. I certify there is no obvious change to the tank system that would cause this tank to become not‐fit for service since it was certified by a PE, API or STI inspector on

_______________________ (date). This certification meets the requirements set in WV CSR 47‐63‐5.2.b.3 to certify annual inspections in intervening years between the evaluations required by a PE, API or STI inspector.

In accordance with the WV CSR 47‐63‐5.2, I have documented all deficiencies and/or changes in the tank system found during the inspection, in writing, and provided my recommendations, including a proposed schedule, for abating the deficiencies and submitted them with this form.

I certify that I have personally examined and/or am familiar with the inspection performed on the AST system listed above, including its associated equipment, leak detection system and secondary containment structure, and that based on my direct knowledge that the AST listed above is Fit for Service.

Signature of Certifying Individual Date Signed

P.E. Registration #, STI Certification # or Registration/Certification Expiration Date API

Certification # (if applicable) (if applicable)

AST Facility Name

Address

City, State, Zip

Tank Owner Name

Telephone Number

Email Address

Certifying Individual

Address

City, State, Zip

Telephone Number

Email Address

Facility’s/Owner’s Tank ID

DEP Issued Tank Label

DEP Determined Tank Level Level 1 tank ☐ Level 2 tank ☐