Questionnaire Nj Form – Fill Out and Use This PDF

The Questionnaire NJ form is a crucial document for the New Jersey Department of Environmental Protection, specifically for their Site Remediation and Waste Management Program. This form is designed to fulfill the registration needs under the Underground Storage of Hazardous Substances Act, ensuring that underground storage tank (UST) facilities comply with state regulations. The form requires detailed information about the facility, including owner and operator data, financial responsibility proofs, and specifics about the underground storage tanks. To ensure your UST facility meets all required standards and regulations, consider filling out the Questionnaire NJ form by clicking the button below.

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Questionnaire Nj Form PDF Details

The Questionnaire NJ form serves as a pivotal component in adhering to the regulations established under the Underground Storage of Hazardous Substances Act and the accompanying Underground Storage Tank Rules by the New Jersey Department of Environmental Protection. This comprehensive document is crucial for owners or operators of facilities with underground storage tanks (USTs) to ensure their operations align with state-mandated environmental protections. It spans from registering new and existing USTs to detailing changes, corrections, or amendments to existing registrations, including closures or modifications. The form meticulously gathers general facility information, ownership and operator details, including business entity specifics and contact information for various roles such as Class A and B operators and billing contacts. Additionally, it outlines the requirements for demonstrating financial responsibility, a measure designed to ensure that resources are available for taking corrective actions or compensating for damages due to UST system failures. The submission process also accommodates electronic attachments, with specifications on how to submit accompanying documents such as tank information, site plans, and proof of financial responsibility. Furthermore, the form encompasses installer certification for new or returned-to-service UST systems, signifying compliance with state and manufacturer installation standards. Altogether, the meticulous detail and comprehensive nature of the Questionnaire NJ form underscore its importance in the environmental regulatory framework, aiming to safeguard public health and the environment from potential hazards associated with underground storage systems.

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Form Name	Questionnaire Nj Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	njdep ust registration form, questionnaire nj form printable, njdep questionaire nj, njdep questionnaire form

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For State use only: Check Received

Yes

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)

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	Page 1 of 7
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UST Facility # _________________

4. Facility Type

State Commercial/Industrial

County/Municipal Federal

Charitable / Public School Residential

Farm

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

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

Yes

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	Page 2 of 7
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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	Page 3 of 7
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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	Page 4 of 7
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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 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	Page 5 of 7
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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	Page 6 of 7
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.

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 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.

Leaded Gasoline

Unleaded Gasoline

Alcohol Enriched Gasoline (> 10%)

Light Diesel Fuel (No. 1-D)

Medium Diesel Fuel (No. 2-D)

Waste Oil

Kerosene (No. 1)

Heating Oil (No. 2) Complete 11C

Heating Oil (No. 4) Complete 11C

Heating Oil (No. 6) Complete 11C

Aviation Fuel

Motor Oil

Lubricating Oil

Automatic Transmission Fluid

Hazardous Waste (Specify ID Number)

_____________

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)

Bare steel

Cathodically Protected Metal

1. Sacrificial Anode (SA)

2. Impressed Current (IC)

Date SA/IC installed:

_____________

Date of last passing CP inspection:

_____________

Fiberglass-Coated Steel (Tank Only)

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 Identification Number

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

(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

(Check one for each tank)

9. Spill Containment Around Fill Pipe

Yes

(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 Identification Number

10. Tank Status Information

In-Use

Out of Service

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

_____________

____________

_____________

Out of Service extension approval #:

_____________

____________

_____________

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

Sump

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)

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

_____________

Substantial Modification #

_____________

UST Facility Certification Questionnaire Form - UST 021	Attachment A Page 3 of 3
Version 2.2 07/27/18

How to Edit Questionnaire Nj Form Online for Free

ust registration can be filled out easily. Just make use of FormsPal PDF tool to finish the job fast. In order to make our tool better and simpler to use, we constantly develop new features, with our users' suggestions in mind. Should you be looking to get started, here's what you will need to do:

Step 1: Open the PDF form in our editor by clicking the "Get Form Button" above on this webpage.

Step 2: This tool helps you modify your PDF file in a variety of ways. Change it by adding customized text, adjust original content, and place in a signature - all close at hand!

So as to fill out this document, be certain to type in the required information in each and every blank:

1. Fill out your ust registration with a group of essential blanks. Get all of the important information and ensure absolutely nothing is neglected!

2. Given that the previous part is complete, you're ready to include the required specifics in 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, Type of Submission Check all that, a b c, Registration of a newly installed, If c is checked above please check, UST Facility Name andor Address, and Change in Type of Products Stored so you can progress to the next stage.

Part number 2 of submitting njdep questionaire nj

3. Completing UST Facility Name andor Address, Change in Type of Products Stored, Other please specify, Total number of regulated, Total capacity of regulated, UST Facility Certification, and Page of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

njdep questionaire nj writing process explained (portion 3)

4. This specific section arrives with these particular blanks to complete: Facility Type, UST Facility, State CommercialIndustrial, CountyMunicipal Federal, Charitable Public School, Farm, Is this facility a retail service, Yes, Is this facility a heating oil, Yes, SECTION B UST FACILITY OWNER AND, UST Facility Owner Owner of tanks, Name of UST Facility Owner, Mailing Address, and Municipality State Zip Code.

njdep questionaire nj conclusion process clarified (portion 4)

It is possible to make an error while filling out your SECTION B UST FACILITY OWNER AND, so make sure that you look again before you decide to send it in.

5. This pdf needs to be completed by going through this segment. Below you have a full list of fields that need to be filled out with accurate information in order for your document submission to be accomplished: Phone Number Ext Fax, Email Address, If the owner is a corporation a, NJ Business Entity digit ID Type, Date of original business, Name of the corporate officer, regarding this UST Facility, Phone Number, Email Address, UST Facility Operator, Same as UST Facility Owner, Attach additional pages if, If change to facility operator, Add this operator, and Replace prior operator with this.

Email Address, If change to facility operator, and Replace prior operator with this in njdep questionaire nj

Step 3: Right after taking one more look at your fields and details, hit "Done" and you're good to go! Sign up with FormsPal right now and immediately use ust registration, set for downloading. Every modification made is handily kept , so that you can modify the form at a later stage anytime. We do not sell or share the details you enter while dealing with documents at our site.

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