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In the landscape of environmental protection and regulatory compliance, the completion of the Underground Storage Tank (UST) Facility Certification Questionnaire by the New Jersey Department of Environmental Protection (NJDEP) represents a crucial juncture for operators and owners of UST facilities. This comprehensive document, vital for adhering to the Underground Storage of Hazardous Substances Act and the Underground Storage Tank rules, outlines a structured process for the registration, modification, and management of UST facilities within New Jersey. It serves a dual purpose not only as a registration requirement but also as a tool for the NJDEP to monitor and enforce environmental and public health protections. The questionnaire is meticulously designed to collect detailed information about the facility including general operational data, ownership details, the total number and capacity of tanks, and specifics regarding the containment of substances. Furthermore, it mandates the disclosure of financial responsibility mechanisms, ensuring that UST owners and operators are adequately prepared to address potential releases of hazardous materials. It calls for transparency and accuracy in the reporting of operational changes, modifications, or closures, punitive measures are in place for the submission of false or incomplete information. It underscores the readiness of UST systems for service and highlights the requirement for electronic submission of supporting documents, facilitating a streamlined review process by the NJDEP. This foundational aspect of New Jersey’s environmental regulatory framework underscores a commitment to safeguarding both the environment and public health through meticulous oversight and regulation of underground storage facilities.

Sample - Questionnaire Nj Form

For State use only: Check Received

Yes

No

New Jersey Department of Environmental Protection

Site Remediation and Waste Management Program

UNDERGROUND STORAGE TANK FACILITY CERTIFICATION QUESTIONNAIRE

Date Stamp

(For Department use only)

Completion of this UST Facility Certification Questionnaire will satisfy the registration requirements of the Underground Storage of Hazardous Substances Act, N.J.S.A. 58:10A-21 et seq., and the Underground Storage Tank Rules N.J.A.C. 7:14B et. seq. An owner or operator’s submission of false, inaccurate, or incomplete information on this Questionnaire constitutes a violation of these regulations and may result in a delay or denial of a Registration.

SECTION A. GENERAL FACILITY INFORMATION

UST Facility # (Program Interest ID): ____________________

UST Facility Name: _________________________________________________________________________________________

Street Address: _____________________________________________________________________________________________

Municipality: ______________________________________________

(Township, Borough or City)

County: __________________________________________________

Zip Code: _____________________________________

List the name and contact information of the owner of the real property on which the UST facility is located and the municipal Block and Lot numbers of the property:

Real Property Owner: ______________________________________________________________________________________

Contact Person: ___________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________ Zip Code: ______________

Phone Number: ___________________________Email Address: _________________________________________________

Block # _______________

Lot #(s) __________________

Block # ______________

Lot #(s) __________________

Block # _______________

Lot #(s) __________________

Block # ______________

Lot #(s) __________________

Block # _______________

Lot #(s) __________________

Block # ______________

Lot #(s) __________________

1.Type of Submission (Check all that apply)

a)

b)

c)

d)

Registration of a newly installed underground storage tank(s). (Complete Attachment A)

Registration of an existing underground storage tank not presently registered. (Complete Attachment A) Change, correction, or amendment to an existing facility registration (Check type of change, correction, or amendment below)

Annual renewal

If “c” is checked above, please check the appropriate type of change, correction, or amendment below (check all that apply)

UST Facility Name and/or Address UST Facility Owner and/or Address UST Facility Operator and/or Address Property Owner Name

Class A or B Operator Billing Contact Person

Change in Type of Product(s) Stored (Complete Attachment A - 3) Substantial Modification(s) (Complete Attachment A - 12B) Tank(s) and/or Piping (Complete Attachment A)

Closure (Complete Attachment A - 3, 4,10C)

Financial Responsibility (Attach whole policy listing all tanks)

Other (please specify): _____________________________________________________________________________

2.Total number of regulated underground storage tanks at facility: ___________________

3.Total capacity of regulated underground storage tanks at facility (gallons): ___________________

UST Facility Certification Questionnaire Form - UST 021

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Version 2.2 07/27/18

 

UST Facility # _________________

4. Facility Type

State

County/Municipal

Charitable / Public School

Commercial/Industrial

Federal

Residential

5.Is this facility a retail service station?...................................................................................................

6.Is this facility a heating oil sales / distribution center?.........................................................................

Farm

Yes

Yes

No

No

SECTION B. UST FACILITY OWNER AND OPERATOR INFORMATION 1. UST Facility Owner (Owner of tanks)

Name of UST Facility Owner: _________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Name of UST Facility Owner Contact: ____________________________________________

Title: _____________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________ Zip Code: _______________

Phone Number: _______________________________ Ext: _____________________ Fax: __________________________

Email Address: _____________________________________________________________________________________________

If the owner is a corporation, a limited liability company, a partnership, a limited partnership, or other form of business complete the following:

NJ Business Entity 10-digit ID #: ___________________ Type of business entity: _________________________________

Date of original business formation or date registration filed with the State: _____________________________________

Name of the corporate officer, partner, or other person with primary decision making authority

regarding this UST Facility: ______________________________________________________________________________

Phone Number: ________________________________________________________________________________________

Email Address: _________________________________________________________________________________________

2. UST Facility Operator

Same as UST Facility Owner

(Attach additional pages if necessary)

If change to facility operator, check one:

 

Add this operator

Replace prior operator with this operator

Name of UST Facility Operator: _______________________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________ Zip Code: _______________

Name of UST Facility Operator Contact: _______________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Phone Number: __________________________________ Ext: ________________________

Fax: _____________________

Email Address: _____________________________________________________________________________________________

UST Facility Certification Questionnaire Form - UST 021

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UST Facility # _________________

If the operator is a corporation, a limited liability company, a partnership, a limited partnership, or other form of business complete the following:

NJ Business Entity 10-digit ID #: ___________________Type of business entity: _________________________________

Date of original business formation or date registration filed with the State: _____________________________________

Name of the corporate officer, partner, or other person with primary decision making authority

regarding this UST Facility: ______________________________________________________________________________

Phone Number: ______________________________ Ext: ________________________ Fax: _____________________

Email Address: _________________________________________________________________________________________

3. Class A Operator

Name: ____________________________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Phone Number: __________________________________ Ext: ________________________

Fax: _____________________

Email Address: _____________________________________________________________________________________________

Provide the NJ Registration and Validation Numbers, which can be found on the examination results page. If you received training/certification in another state, provide the name of the state from which you received training and attach formal documentation of training received and/or record of a passing evaluation.

NJ Registration Number: _____________________

and Validation Number: ___________________

OR, if training received out of state:

Name of State where training occurred: ________________________________ (attach training documentation)

4. Class B Operator

Same as Class A Operator

Name: ____________________________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Phone Number: __________________________________ Ext: ________________________

Fax: _____________________

Email Address: _____________________________________________________________________________________________

Provide either the NJ examination result numbers or, if you received training/certification in another state, provide the name of the state from which you received training and attach formal documentation of training received and/or record of a passing evaluation.

NJ Registration Number: _____________________

and Validation Number: ___________________

OR, if training received out of state:

Name of State where training occurred: ________________________________ (attach training documentation)

5.Billing Contact Check the appropriate box:

Same as Facility Owner

Same as Facility Operator

Other – provide contact information below

Name of UST Facility: _______________________________________________________________________________________

Name of UST Facility Billing Contact: ________________________________ Title: ___________________________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Phone Number: __________________________________ Ext: ________________________

Fax: _____________________

Email Address: _____________________________________________________________________________________________

UST Facility Certification Questionnaire Form - UST 021

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UST Facility # _________________

SECTION C. FINANCIAL RESPONSIBILITY (Attach additional pages if necessary)

Include entire Financial Responsibility Assurance Mechanism Document

Type of Mechanism (e.g., Insurance): __________________________________________________________________________

Carrier/Issuing Institution: _____________________________________________________________________________________

Name of Insured: ____________________________________________________ Policy Number: _______________________

Effective Date: _______________ Expiration Date: ______________________

Limit of Liability: Each “Occurrence” or “Incident”: .. _______________________

Limit of Liability: Aggregate:

_______________________

Limit of Defense Costs:

_______________________

(Defense costs must be subject to a separate policy limit as provided in 40 CFR 280.97)

Retroactive Dates(s): _________________________________________________

(attach or Identify Insurer’s Schedule of Covered UST Systems Providing This Information)

SECTION D. ATTACHMENTS

The owner and operator can submit attachments to the NJDEP electronically by emailing them to: srpustregistration@dep.nj.gov. The owner and operator must save the documents in Adobe Portable Document Format (PDF) and then add them as attachments to the email. The owner and operator shall include in the email subject line the UST Facility # (Program Interest ID) and the year, separated by a comma.

Example: You are submitting for XYZ facility in Hamilton Twp. with the UST Facility # of 013164. So, the Email Subject Line

should be only: 013164,2016.

Indicate below how you have included each of the following attachments with this submission:

Attached Emailed

Attachment A – Specific Tank Information (if applicable)

Facility Site Plan (if applicable)

You are required to submit a Facility Site Plan only for the initial registration of a tank or if there are any changes to the physical configuration of the tank system or property. You must include in the facility site plan the location of the tanks, lines, pumps, dispensers, fill pipes, and other features of the underground storage tank system, including the distance from existing buildings and property boundaries;

Financial Responsibility Assurance Mechanism (entire document always required)

Owner’s copy of written authorization authorizing the signature above. (if applicable)

Operator’s copy of written authorization authorizing the signature above. (if applicable)

Other (specify): __________________________________________________________________________

UST Facility Certification Questionnaire Form - UST 021

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UST Facility # _________________

SECTION E. INSTALLER CERTIFICATION

(To be completed by installer for new UST installations or returning out-of-service USTs to service)

Purpose of Certification (check all that apply)

Certification of New UST Installation

Certification that out-of-service USTs are properly designed and capable of being put back into service

Check the applicable boxes to indicate the methods used to comply with installation/return-to-service requirements. (Attach additional pages if necessary)

Tank No.

 

Tank No.

 

Tank No.

 

Tank No.

Tank Identification Number

Installer certified by tank and piping manufacturers

Installer certified or licensed by the NJDEP

Installation is/will be in accordance with manufacturers installation checklists

Company: _________________________________________ Installation-Entire UST System License #: _________________

Mailing Address: ____________________________________________________________________________________________

Municipality: ______________________________________________ State: ______________

Zip Code: _______________

Phone Number: __________________________________ Ext: ________________________

Fax: _____________________

Email Address: _____________________________________________________________________________________________

Signature of UST installer certifies that the UST System and/or out-of-service UST system is/are properly designed and capable of being put back into service:

Signature: ______________________________________________________________ Date: _____________________

Name: _________________________________________________ Title: __________________________________________

UST Facility Certification Questionnaire Form - UST 021

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UST Facility # _________________

SECTION F. FACILITY OWNER CERTIFICATION

Must be signed as follows:

•For a corporation, by a responsible corporate official.

•For a partnership or sole proprietorship, by a general partner or the proprietor, respectively.

•For a municipality, County, State, Federal or other public agency, by either a principal executive officer or ranking elected official.

•For a person other than those indicated above, a duly authorized representative.

“I certify under penalty of law that:

1.I have read, understand, and have followed the applicable rules and instructions for this New Jersey Underground Storage Tank Facility Certification Questionnaire;

2.I have personally examined and am familiar with the information submitted in this New Jersey Underground Storage Tank Facility Certification Questionnaire and all attached documents;

3.I believe, based on my inquiry of those individuals responsible for obtaining the information, that the submitted information is true, accurate and complete;

4.This facility is in compliance with N.J.A.C. 7:14B; and

5.I am the person required, pursuant to N.J.A.C. 7:14B-2.2, to sign this New Jersey Underground Storage Tank Facility Certification Questionnaire for the owner of this facility.

6.I am aware that there are significant civil penalties for knowingly submitting false, inaccurate or incomplete information and that I am committing a crime of the fourth degree if I make a written false statement which I do not believe to be true. I am also aware that if I knowingly direct or authorize the violation of any statute or regulation, I am personally liable for penalties.”

Signature: _______________________________________________________________ Date: _____________________

Name: _________________________________________________ Title: ___________________________________________

UST Facility #: _____________________

UST Facility Certification Questionnaire Form - UST 021

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Version 2.2 07/27/18

 

UST Facility # _________________

SECTION G. FACILITY OPERATOR CERTIFICATION

Must be signed as follows:

•For a corporation, responsible corporate official.

•For a partnership or sole proprietorship, by a general partner or the proprietor, respectively.

•For a municipality, County, State, Federal or other public agency, by either a principal executive officer or ranking elected official.

•For a person other than those indicated above, a duly authorized representative.

“I certify under penalty of law that:

1.I have read, understand, and have followed the applicable rules and instructions for this New Jersey Underground Storage Tank Facility Certification Questionnaire;

2I have personally examined and am familiar with the information submitted in this New Jersey Underground Storage Tank Facility Certification Questionnaire and all attached documents;

3.I believe, based on my inquiry of those individuals responsible for obtaining the information, that the submitted information is true, accurate and complete;

4.This facility is in compliance with N.J.A.C. 7:14B; and

5.I am the person required, pursuant to N.J.A.C. 7:14B-2.2, to sign this New Jersey Underground Storage Tank Facility Certification Questionnaire for an operator of this facility.

6.I am aware that there are significant civil penalties for knowingly submitting false, inaccurate or incomplete information and that I am committing a crime of the fourth degree if I make a written false statement which I do not believe to be true. I am also aware that if I knowingly direct or authorize the violation of any statute or regulation, I am personally liable for penalties.”

Signature: ______________________________________________________________ Date: _____________________

Name: _________________________________________________ Title: __________________________________________

UST Facility #: _____________________

Annual renewal with a billing invoice

If a billing invoice has been received for an annual renewal (only), send the completed UST Facility Certification Questionnaire (USTFCQ) with attachments, the applicable $50 fee, and the invoice payment stub to:

NJ Department of Treasury

Division of Revenue

PO Box 417

Trenton, NJ 08646-0417

All Other Types of Submissions

All other submissions for initial registrations, modifications and responses to deficiencies must be submitted to the address below. Send the completed USTFCQ with attachments and any applicable fee to:

NJ Department of Environmental Protection

Site Remediation and Waste Management Program Bureau of Case Assignment and Initial Notice UST Registration & Billing Unit

401-05H PO Box 420

Trenton, NJ 08625-0420

UST Facility Certification Questionnaire Form - UST 021

Page 7 of 7

Version 2.2 07/27/18

 

UST Facility # _________________

ATTACHMENT A

SPECIFIC TANK INFORMATION

ALL regulated underground storage tanks, including those taken out of operation (unless the tank was removed from the ground prior to 9/3/86) must be registered. Report all tank/piping status changes.

 

 

 

 

 

 

Tank No.

 

 

Tank No.

 

 

 

Tank No.

 

 

Tank No.

 

 

 

 

Tank Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Date Tank Installed (mm/dd/yyyy)

 

_____________

 

_____________

 

 

_____________

 

_____________

 

 

 

 

2. Tank Size (gallons)

 

____________

 

____________

 

 

____________

 

____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Tank Contents (check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please note that each compartment is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

considered a separate tank system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

Leaded Gasoline

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Unleaded Gasoline

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Alcohol Enriched Gasoline (> 10%)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

Light Diesel Fuel (No. 1-D)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.

Medium Diesel Fuel (No. 2-D)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F.

Waste Oil

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G.

Kerosene (No. 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H.

Heating Oil (No. 2) Complete 11C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I.

Heating Oil (No. 4) Complete 11C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J.

Heating Oil (No. 6) Complete 11C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K.

Aviation Fuel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L.

Motor Oil

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M.

Lubricating Oil

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N.

Automatic Transmission Fluid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O.

Hazardous Waste (Specify ID Number)

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

P.

Coolant/Antifreeze

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Q. Other (please specify)

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAS Number (Hazardous substances only)

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Tank & Piping Construction

 

 

Tank

 

Piping

 

 

Tank

 

Piping

 

 

 

Tank

 

Piping

 

 

Tank

 

Piping

 

 

 

 

(Check at least one for each Tank and Piping)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

Bare steel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Cathodically Protected Metal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Sacrificial Anode (SA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Impressed Current (IC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date SA/IC installed:

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

Date of last passing CP inspection:

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Fiberglass-Coated Steel (Tank Only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

Fiberglass-Reinforced Plastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UST Facility Certification Questionnaire Form - UST 021

Attachment A Page 1 of 3

Version 2.2 07/27/18

 

 

 

 

 

 

 

 

 

 

 

 

 

UST Facility #

_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tank No.

 

Tank No.

 

 

Tank No.

 

Tank No.

 

 

 

 

Tank Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tank

 

 

Tank

 

 

 

Tank

 

Tank

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Internally Lined

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single lining

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Double walled lining

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Internal Lining Installed:

 

_____________

_____________

_____________

_____________

 

 

 

 

 

Date of last passing inspection:

 

_____________

_____________

_____________

_____________

 

 

F.Other (Please specify, include Brand Name)

 

5. Piping Operation

 

Piping

 

Piping

 

 

 

Piping

 

Piping

 

 

(Check one for each tank system)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Pressurized Piping

B. American Suction Piping

C. European Suction Piping

 

D. Supply/Return (Heating Oil Piping Only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Tank & Piping Structure

 

 

Tank

 

Piping

 

Tank

 

Piping

 

 

 

Tank

 

Piping

 

Tank

 

 

Piping

 

 

(Check all that apply for Tank & Piping)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Single Wall

B. Double Wall

C. Secondary Containment

(e.g. Externally Lined)

 

D. No piping exists

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Type of Monitoring/Detection

 

 

Tank

 

Piping

 

Tank

 

Piping

 

 

 

Tank

 

Piping

 

Tank

 

Piping

 

 

(Check all that apply for Tank & Piping)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Statistical Inventory Reconciliation

B. Manual Tank Gauging

C. Inventory Control

D. Interstitial

E. Tightness Test

F. Ground Water Observation Wells

G. Vapor Observation Wells

H. In-Tank (Auto Monitoring Gauge)

I. In-Line Electronic Pressure Monitoring

J. Automatic Line Leak Detector

 

 

K. None

 

 

 

 

 

 

 

 

 

 

 

8. Overfill Protection

 

Yes

No

Yes

No

Yes

No

Yes

No

 

 

 

(Check one for each tank)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Spill Containment Around Fill Pipe

 

Yes

No

Yes

No

Yes

No

Yes

No

 

 

 

(Check one for each tank)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UST Facility Certification Questionnaire Form - UST 021

Attachment A Page 2 of 3

Version 2.2 07/27/18

 

 

 

 

 

 

 

 

 

 

 

 

 

UST Facility #

_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tank No.

 

Tank No.

 

Tank No.

 

 

Tank No.

 

 

 

Tank Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Tank Status Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

In-Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Out of Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Taken Out of Service (mm/dd/yyyy)

 

_____________

____________

 

_____________

 

_____________

 

 

 

 

Out of Service extension approval #:

 

_____________

____________

 

_____________

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Closed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Removed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Removed (mm/dd/yyyy)

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

Activity #

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

2. Abandoned-In-Place

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Abandoned-In-Place

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

Activity #

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

11. Tank Use Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Emergency Back-up Generator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Sump

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Heating Oil Tanks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked I, J or K under item

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3, check one of the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Heating Oil for on-site consumption

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Heating Oil for sale or distribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Other Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

Date of Sale or Transfer (mm/dd/yyyy)

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

B.

Substantial Modification #

 

_____________

 

_____________

 

_____________

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UST Facility Certification Questionnaire Form - UST 021

Attachment A Page 3 of 3

Version 2.2 07/27/18

 

Document Specifications

Fact Name Description
Governing Laws This form is regulated under the Underground Storage of Hazardous Substances Act, N.J.S.A. 58:10A-21 et seq., and the Underground Storage Tank Rules N.J.A.C. 7:14B et. seq.
Primary Purpose The primary purpose of the UST Facility Certification Questionnaire is to satisfy the registration requirements for underground storage tanks in New Jersey.
Consequences of False Information Submission of false, inaccurate, or incomplete information may lead to delays or denial of registration and constitutes a violation of regulations.
Sections Included The form includes sections on general facility information, owner and operator information, financial responsibility, attachments, and installer certification.
Type of Submissions Types of submissions include registration of new or existing unregistered tanks, changes or corrections to an existing facility registration, and annual renewal.
Information Required Information required includes details on the facility, owner, operator, financial responsibility, and certification of installation or return-to-service of tanks.
Financial Responsibility Proof Proof of financial responsibility must be provided as part of the form, detailing the insurance or other assurance mechanisms.
Electronic Submission Attachments can be submitted electronically to the NJDEP with specific instructions on email subject lines and format of documents.

Detailed Steps for Using Questionnaire Nj

Once you've decided to fill out the New Jersey Department of Environmental Protection Site Remediation and Waste Management Program's Underground Storage Tank Facility Certification Questionnaire, you're taking a step towards complying with state regulations regarding the storage of hazardous substances. It's a process that demands attention to detail. Misinformation or incomplete data can lead to delays or denial of registration, which underscores the importance of accuracy. The form includes sections that need careful consideration, including details about the facility, the owner, the operator, financial responsibility, and more.

Here’s a straightforward guide to help you complete the form:

  1. General Information: Start with Section A by entering the facility’s name, address, and other basic information, including contact details for the real property owner.
  2. Type of Submission: In question 1, select the appropriate submission type. If you’re registering a new tank, making changes, or renewing, check the corresponding box.
  3. Facility Detail: Provide the total number of tanks and their total capacity in gallons.
  4. Facility Type & Services: Indicate the facility type and answer the questions about being a retail service station or a heating oil sales/distribution center.
  5. Owner and Operator Information: Fill in detailed information about the UST facility owner and operator in Section B. If the facility operator is different from the owner, make sure to provide the full details for both.
  6. Class A and B Operators: Provide the contact details, training, and certification information for both the Class A and Class B operators.
  7. Billing Contact: Specify who should be contacted for billing purposes. If it’s the same as the facility owner or operator, check the appropriate box. Otherwise, provide the contact details of another person.
  8. Financial Responsibility: Under Section C, attach the complete financial responsibility assurance mechanism document and fill in the required fields about the insurance or financial assurance mechanism you have in place.
  9. Attachments: In Section D, check whether you have included or emailed the necessary attachments, such as Attachment A for specific tank information, facility site plans, financial responsibility documents, and any other required documentation.
  10. Installer Certification: If applicable, the installer must complete Section E, certifying the installation or return-to-service of the USTs.

After completing all the necessary sections and attaching the required documentation, review your entries carefully to ensure accuracy. Once reviewed, submit the form and attachments as directed by the NYDEP to ensure your facility complies with New Jersey’s environmental protection regulations.

Learn More on Questionnaire Nj

What is the purpose of the UST Facility Certification Questionnaire in New Jersey?

The UST Facility Certification Questionnaire is designed to meet the registration requirements set by the Underground Storage of Hazardous Substances Act, N.J.S.A. 58:10A-21 et seq., and the Underground Storage Tank Rules N.J.A.C. 7:14B et. seq. in New Jersey. Its completion is mandatory for owners or operators of underground storage tank (UST) facilities to officially document and certify information regarding the tanks, including ownership, location, and compliance status. Submitting false, inaccurate, or incomplete information can lead to penalties, including delays or denial of the registration.

What information must be provided in Section A of the Questionnaire?

In Section A, General Facility Information, the form requires comprehensive details about the UST facility. This includes the UST Facility Number, name, street address, municipality, county, zip code, and information about the real property owner including their contact details, municipal block and lot numbers.

What are the types of submissions indicated in the Questionnaire?

There are several submission types detailed in the Questionnaire, allowing various updates and changes to be reported:

  • Registration of a newly installed underground storage tank(s).
  • Registration of an existing underground storage tank not presently registered.
  • Change, correction, or amendment to an existing facility registration including changes to UST facility name/address, owner/address, operator/address, property owner name, type of product(s) stored, and more.
  • Annual renewal of the registration.

How does an owner or operator indicate changes to the UST facility?

If there are any changes, corrections, or amendments needed for an existing UST facility registration, the owner or operator must check the appropriate type of change in the "Type of Submission" section and provide the required information for each applicable change, ensuring all relevant portions of Attachment A are completed based on the type of change (e.g., change in type of product stored, substantial modifications, closure, financial responsibility).

What is required for demonstrating financial responsibility according to Section C?

Section C requires the submission of an entire Financial Responsibility Assurance Mechanism Document. The type of mechanism (e.g., insurance), carrier/issuing institution, name of the insured, policy number, effective and expiration dates, limits of liability for each occurrence or incident, aggregate limit, and limit of defense costs must be detailed. If applicable, it should also include retroactive dates and a schedule of covered UST systems.

What attachments are required to be submitted along with the Questionnaire?

Various attachments may need to be included with the Questionnaire submission, depending on the facility’s circumstances:

  • Attachment A – Specific Tank Information (if applicable).
  • Facility Site Plan – Required for initial registration or for any physical configuration changes of the tank system or property.
  • Financial Responsibility Assurance Mechanism - The entire document is always required.
  • Authorization documents - If applicable, for owner and operator signature authorization.
  • Other specified documents.
These documents can be submitted electronically by email, adhering to the instructions provided in the Questionnaire.

Common mistakes

When completing the Underground Storage Tank Facility Certification Questionnaire for the New Jersey Department of Environmental Protection, individuals often make mistakes that can have significant consequences, such as delays or denials of Registration. Understanding and avoiding these common errors can streamline the process and ensure better compliance. Here are seven common mistakes to watch out for:

  1. Failing to check all applicable types of submission in Section A under "Type of Submission". This section helps identify the nature of the registration, and missing information can result in processing delays.

  2. Incorrect or incomplete information about the real property owner’s contact details and the municipal Block and Lot numbers of the property. Accurate details are crucial for the verification process and any future correspondence.

  3. Omitting details regarding the total number and capacity of regulated underground storage tanks at the facility in Section A. This information is essential for understanding the scope of potential environmental impacts.

  4. Not providing accurate UST Facility Owner and Operator information in Section B. This includes the name, mailing address, municipality, zip code, and contact information. Misinformation or omissions can complicate ownership verification and operational responsibility.

  5. Forgetting to indicate changes in the type of product stored, substantial modifications, or tank closures in Section A when applicable. Such changes directly affect the facility's environmental and safety assessments.

  6. Incomplete financial responsibility documentation as required in Section C. This section is critical to ensure there are funds or insurance to address potential releases from USTs, which is a regulatory requirement for operating such facilities.

  7. Failure to include required attachments as specified in Section D or incorrectly labeled email subject lines when submitting documents electronically. Proper documentation supports the application, and incorrect submission can delay the review process.

To enhance the chances of a smooth registration process, applicants should meticulously review each section of the Questionnaire before submission, ensuring that all applicable parts are completed in full and accurately reflect the current status and specifics of the UST facility. Documenting the facility's compliance with state regulations is a critical responsibility, and close attention to the details in the Questionnaire can help facilitate this process.

Documents used along the form

When submitting the Underground Storage Tank Facility Certification Questionnaire for the New Jersey Department of Environmental Protection's Site Remediation and Waste Management Program, several complementary documents are frequently required to ensure comprehensive compliance and registration. Understanding each of these documents is crucial for a smooth submission process.

  • Attachment A – Specific Tank Information: This attachment is crucial for both new and existing underground storage tanks (USTs). It details the specific characteristics of each tank, such as size, construction material, and contents. For new installations or when changes occur in the stored substances, a complete and updated Attachment A is essential to assess compliance with environmental standards.
  • Facility Site Plan: A site plan is mandatory for initial registrations and any subsequent changes to the tank system's physical layout or the property itself. It provides a bird's eye view of the tank locations, fill pipes, lines, and other relevant infrastructure. This graphical representation helps in understanding the spatial arrangement and ensuring that UST installations meet safety and environmental requirements.
  • Financial Responsibility Assurance Mechanism: Demonstrating financial responsibility is required under both federal and state laws. This document proves that the UST owner/operator can cover the costs associated with cleaning up accidental releases and compensating affected parties. It typically includes insurance policies, but other mechanisms like surety bonds or letters of credit are also accepted. The complete document, not just a summary, must be attached.
  • Installer’s Certification: For new installations or when returning out-of-service USTs to service, the certification from the installer verifies that the installation meets all design and regulatory standards. It affirms that the installer is qualified and that the UST system is apt for operation. This certification plays a pivotal role in ensuring public safety and environmental protection.

Together, these documents form a comprehensive package that, alongside the UST Facility Certification Questionnaire, facilitates an accurate and lawful registration process. It's important for facility owners and operators to gather and prepare these documents with diligence to ensure compliance with all New Jersey environmental regulations and standards for underground storage tanks.

Similar forms

The "Business Registration Form" for new enterprises is closely related to the Questionnaire NJ form, particularly in sections dealing with UST Facility Owner information that aligns with business entity details required during the registration of a business. Both forms collect comprehensive details about the business, including the business name, contact information, business type (corporation, LLC, etc.), and identification numbers, which are pivotal for registering and identifying the business officially within a state or regulatory framework. The structured collection of business entity information ensures proper commissioning and compliance with state regulations.

The "Environmental Compliance Form," similarly, echoes the segments of the Questionnaire NJ form that necessitate detailed facility information, such as the physical address, municipality, county, and specifics about the underground storage tanks. The emphasis on environmental compliance is interwoven with the facility’s operational details to ensure that the operation of underground storage tanks adheres to state environmental protection standards, focusing on safe storage practices and minimizing the environmental impact.

A "Change of Ownership Form" typically used in various legal and business contexts also finds its parallel in the portion of the Questionnaire NJ form where a change, correction, or amendment to existing facility registration is mentioned. This resemblance is marked by the procedure to officially record any changes in the ownership or operational responsibility of the UST facility, ensuring that all pertinent details are up-to-date and accurate, which is essential for both legal clarity and regulatory compliance.

"Insurance Coverage Forms" are closely related to the section of the Questionnaire NJ form concerning financial responsibility. Both documents require detailed information on the insurance carrier, policy number, effective dates, and coverage limits. This is crucial for demonstrating that the UST facility has adequate financial backing to cover any potential environmental cleanup efforts, accidents, or incidents arising from the operation of the underground storage tanks, thus ensuring public and environmental safety.

Lastly, the "Facility Site Plan Submission" requirement aligns with the Document Type and Attachment A stipulations of the Questionnaire NJ form. These documents focus on the need for a detailed layout of the facility, indicating the location of tanks, lines, and other pertinent infrastructure. The requirement ensures that there is a comprehensive understanding of the facility’s setup, facilitating oversight, inspection, and any necessary environmental or safety interventions. It serves as a blueprint to assess compliance with regulations and facilitate emergency response actions.

Dos and Don'ts

When completing the Underground Storage Tank (UST) Facility Certification Questionnaire for New Jersey, it's essential to follow certain dos and don'ts to ensure compliance and avoid any potential issues with your registration. The questionnaire is a critical document required by the New Jersey Department of Environmental Protection under the Underground Storage of Hazardous Substances Act and the Underground Storage Tank rules. To assist with this process, here is a list of recommended actions and practices to avoid.

Things You Should Do
  • Provide complete and accurate information: Ensure all details about the UST facility, including facility name, address, owner, and operator information, are fully and accurately completed to reflect current circumstances.
  • Check for completeness: Review the entire questionnaire carefully to make sure no sections relevant to your facility are left blank, unless specifically directed in the instructions.
  • Attach required documentation: Submit all necessary attachments, such as the Facility Site Plan and Financial Responsibility Assurance Mechanism document, as these are integral parts of demonstrating compliance with regulations.
  • Maintain consistency in information: Ensure that the information provided is consistent throughout the questionnaire and with any attachments. Discrepancies can lead to questions of accuracy and may delay the registration process.
Things You Shouldn't Do
  • Omit the contact information: Neglecting to fill out comprehensive contact details for the facility owner, operator, and billing contact can lead to communication issues, potentially delaying the approval process.
  • Submit outdated or inaccurate documents: Attaching documents that are outdated or don't accurately reflect the current state of the UST facility can lead to a rejection of your registration.
  • Forget to check for regulation updates: Failing to verify that your submission complies with the most current state and federal UST regulations could result in non-compliance and possible fines.
  • Provide false information: Submitting false, inaccurate, or incomplete information not only violates regulations but may also subject the facility owner or operator to legal consequences, including delays or denial of registration.

Adhering to these guidelines when filling out the UST Facility Certification Questionnaire will help ensure a smoother registration process with the New Jersey Department of Environmental Protection and aid in maintaining compliance with state regulations.

Misconceptions

When it comes to the Underground Storage Tank (UST) Facility Certification Questionnaire in New Jersey, there are numerous misconceptions that can potentially lead to confusion for business owners and operators. Here is a breakdown of seven common misunderstandings:

  • Only petrol stations need to submit this form. This misunderstanding overlooks a vast range of facilities that use underground storage tanks for various substances, not just gasoline. Any facility operating USTs for storing hazardous substances needs to comply, regardless of its primary business operation.

  • Completing the form is a one-time requirement. In fact, updates or changes, such as a change in facility ownership, tank information, or contact details, necessitate re-submitting the form. Additionally, annual renewals might be required, keeping the department informed of the current status.

  • All sections of the questionnaire must be completed by the facility owner. While primarily the responsibility of the owner, certain sections might require input or verification from other parties such as the UST installer or the facility operator, especially concerning technical details and certifications.

  • Submission of false information is of little consequence. Providing false, incomplete, or inaccurate information is a serious violation of New Jersey's environmental regulations, which can result in penalties, including delays or denial of the UST registration.

  • Electronic submissions are not allowed. The form and accompanying documents can indeed be submitted electronically, which is encouraged for efficiency and environmental reasons. The correct email address and format for submission are provided within the form instructions.

  • Financial responsibility proof is optional. Demonstrating financial responsibility is mandatory, reflecting the facility's capability to address potential environmental cleanup and damages stemming from UST incidents. The details of the insurance or other financial assurance mechanisms must be thoroughly documented.

  • The form is only concerned with tank specifications. While the questionnaire does require detailed information about the tanks, it also encompasses broader areas such as general facility information, operator certification, and financial responsibility. The comprehensive nature of the questionnaire ensures that all factors related to UST management and safety are addressed.

Understanding these common misconceptions about the New Jersey Department of Environmental Protection's UST Facility Certification Questionnaire can significantly streamline the compliance process, ensuring that facilities fulfill their legal obligations efficiently and effectively.

Key takeaways

  • When completing the Questionnaire NJ form for the New Jersey Department of Environmental Protection, it's crucial to provide accurate, complete, and truthful information. False or incomplete submissions can lead to violations, delays, or denial of registration under the Underground Storage of Hazardous Substances Act and Underground Storage Tank Rules.
  • The form is designed to satisfy the registration requirements for underground storage tanks (USTs), which includes providing general facility information such as UST Facility ID, name, address, and details about the real property owner, including contact information and block and lot numbers.
  • Applicants must specify the type of submission—whether it's for registration of a newly installed or an existing but not yet registered UST, a change or correction to an existing facility registration, or an annual renewal. Details regarding any changes, including facility name, address, owner, operator, or type of product stored, must be clearly indicated.
  • Complete information about the UST facility owner and operator is required, including names, contact details, and, if applicable, corporate information. For corporations, LLCs, partnerships, and other business entities, the form requests the NJ Business Entity 10-digit ID, type of business entity, and authority figures' details. Operators and owners must also provide information about Class A and B operators, including NJ Registration and Validation Numbers or equivalent out-of-state certifications.
  • Financial responsibility is a critical element of the UST Facility Certification Questionnaire. Applicants must attach the entire Financial Responsibility Assurance Mechanism document, detailing the type of mechanism, carrier or issuing institution, policy number, coverage limits, effective and expiration dates, and defense costs. This documentation proves the applicant's financial ability to cover costs related to UST issues.
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