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