Containment and Integrity Plan Certification Form

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					                                                                                                                                                                        DEP Form # 62-761.890(10)(C)
                  Florida Department of Environmental Protection
                                                                                                                                                                        Form Title Containment and Integrity Plan
                  Twin Towers Office Bldg.•2600 Blair Stone Road•Tallahassee, Florida 32399-2400                                                                                   Certification Form
                                                                                                                                                                        Effective Date July 13, 1998
                                                                                                                                                                        DEP Application No.                           .


          Containment and Integrity Plan Certification Form

    Use this form to notify the Department of Environmental Protection of:

            1. Establishment of the Containment and Integrity Plan.
            2. Certification of secondary containment according to Rule 62-761.890(7), F.A.C.
            3. Recertification of above times.

    Mail to the DEP District Office in your area.


____________________________________ Initial Certification                                                                                       ______________________ Recertification

    1. DEP Facility ID Number: ____________________ 2. Tank Numbers: ________________

    3. Facility Name: _____________________________________________________________

    4. Facility Address: ___________________________________________________________


    I hereby certify or recertify that the tanks covered under following plans (check appropriate blocks)

            Containment and Integrity Plan                                                                                           Certification of Secondary Containment

    comply with the requirements of Rule 62-761.890(7), F.A.C.



                                                                                                                                                                      Signature

    P.E. Registration Number, State of Florida                                                                                                     Name (Type or Print)

                                                                                                                                                                               Date




            Northwest District                   Northeast District                  Central District             Southwest District             South District                     Southeast District
         160 Governmental Center         7825 Baymeadows Way, Suite B 200        3319 Maguire Blvd. Suite 232      3804 Coconut Palm Dr.      2295 Victoria Ave., suite 364       1900 S. Congress Ave. Suite A
         Pensacola, Florida 32501-5794        Jacksonville, Florida 32256-7577      Orlando, Florida 32803-3767        Tampa, Florida 33619        Fort Myers, Florida 33901         West Palm Beach, Florida 33416
               904-463-8300                          904-448-4300                        407-894-7555                    813-744-6100                  813-332-6975                        407-433-2650