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.


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


            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