Sign In
JB Pritzker, Governor
/
James A. Rivera, State Fire Marshal
Skip to Content
Forms /
Applications
Online Applications
Contractor Licensing Applications
Eligibility and Deductible Applications
Online Forms
Blended Fuel Compatibility Form
Certification of Abandonment-In-Place
Certification of Removal
Financial Responsibility
Site Assessment Results
UST Notification Forms
Miscellaneous
UST Applications and Forms
Facility Information
Facility Information (UST Search)
Pay Tank Fees
Tank Fees Online Payment
Permits
Unexpired Permit Search
UST Rules / Statutes
Rules
Statutes
Help Information
Help Manual
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
