ADM-275A NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION EXAMINATIONS LICENSING MAIL CODE 401-04E PO BOX 420 TRENTON NJ 08625-0420 APPLICATION FOR CERTIFICATION OF FIRM UNDER THE PROVISIONS OF P. L. 1991 C. 123 UNDERGROUND STORAGE TANK CERTIFICATION PROGRAM TYPE OF APPLICATION INITIAL RENEWAL MODIFICATION This form supersedes and negates all previous forms submitted. It must be notarized and completed in its entirety with all current information. NOTHING WILL BE PROCESSED WITHOUT THIS FORM AND A PHOTOCOPY OF THE FIRM S CERTIFICATE OF LIABILITY INSURANCE Firm Name Street Address No. Street Physical Location of Firm City State County Zip Code Mailing Address If different from above Owner s Email Address Telephone Number Certification Category Closure Tank Testing Subsurface Evaluation UST Installation check only one Entire UST System Release Detection Monitoring System ONLY UST Corrosion Protection Systems Analyst check only one Cathodic Protection Specialist Additional Business Office....
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How to fill out the Adm 275a Form online
The Adm 275a Form is essential for certification under the underground storage tank certification program in New Jersey. This guide provides clear and comprehensive instructions to help you fill out the form accurately and efficiently online.
Follow the steps to complete the Adm 275a Form online
- Click ‘Get Form’ button to access the Adm 275a Form and open it in your preferred editor.
- Begin by entering the firm name and the physical location details, including street address, city, state, county, and zip code. Ensure all information is accurate and current.
- If your mailing address differs from the physical location, fill in the mailing address section with the required details.
- Provide the owner's email address and telephone number to ensure effective communication regarding the application.
- Select the certification category by checking one of the options: Closure, Tank Testing, or Subsurface Evaluation. Only one option can be selected.
- For UST installation, check either 'Entire UST System' or 'Release Detection Monitoring System ONLY.' This selection is mandatory based on your application type.
- If applicable, select the UST corrosion protection systems analyst option by checking one of the choices: Cathodic Protection Specialist or Cathodic Protection Tester ONLY.
- List additional business offices and their addresses if applicable, ensuring each has a separate certificate generated and displayed at the location.
- Calculate the total fees by adding the initial or renewal fee and any additional business office certificates requested, according to the provided formula.
- Fill in the certifying officer(s) section with the names, titles, UST License numbers, signatures, and the dates. Ensure compliance with the requirements for certifying officers.
- The form must be notarized. Include the date of notarization and the notary public's seal and signature at the bottom of the form.
- Once all fields are filled out, review the document for accuracy. You can then save any changes, download, print, or share the completed form as necessary.
Start completing your Adm 275a Form online today to ensure timely certification for your firm.
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