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JB Pritzker, Governor
/
James A. Rivera, State Fire Marshal
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Blended Fuel Compatibility Form
Certification of Abandonment-In-Place
Certification of Removal
Financial Responsibility
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Certification of Removal
Facility Number
Permit Number
Owner
-
Owner Name
Address
Facility
-
Facility Name
Address
County
Tank #
Capacity in Gallons
Product
Date Removed
Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true.
By checking this box, I certify that the removal of tanks was conducted in accordance with all applicable rules and regulations of the Office of the State Fire Marshal as required by 415 ILCS 5/57.5(f).
Owner/Operator Name:
Date:
Owner/Operator Email:
Owner
Operator
