APPLICATION FOR UST OPERATOR CERTIFICATION
APPLICATION FOR UST OPERATOR CERTIFICATION
Please PRINT or TYPE Date:_______________________
Name of Applicant: (First) (MI) (Last)_______________________
Birthdate: / /__________
Mailing Address: ________________________________________________________________
City: State: Zip Code: __________ County: _____________
Home Phone: Work Phone Cell Phone_________________
Email Address:__________________________________________________________________
EXAM DATE: LOCATION:_________________________________
Circle one: Class A......$25.00 Class B.....$25.00 Class A & B.....$50.00
List all facility names, addresses and ID numbers for which you will be the designated operator.
Facility Name Facility Address Facility ID Number
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you need additional space, please attach a list of all facilities with addresses and ID numbers
In order to have this application processed, the applicant must submit this form and a non-refundable exam fee at least one (1) week prior to the scheduled examination date. Make check or money order payable to the Arkansas Department of Environmental Quality.
Mail to: Arkansas Department of Environmental Quality
Regulated Storage Tanks Division
5301 Northshore Drive
North Little Rock, AR 72118-5317
All the information on this application is true and correct to the best of my knowledge:
Print Name Signature_________________________________
If you have any questions, please call the RST Licensing Division at (501) 682-0993.
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