Form Rev 41 0061 - Professional Certification Confirming Environmental Remedial Action

ADVERTISEMENT

PROFESSIONAL CERTIFICATION CONFIRMING
ENVIRONMENTAL REMEDIAL ACTION
This Certification is to be submitted with an Owner/Agency Certification of Environmental Remedial
Action (Rev 41 0062). On 8 1/2 x 11 paper, please include a copy of the County Assessor’s parcel map or a
similar map showing the property and surrounding area and the approximate location of the proposed
environmental remedial action.
1. I am one of the following:
Certified Underground Storage Tank Service Provider per Chapter 90.76 RCW
Professional Engineer, License No. ____________________________________
Other Environmental Professional Subscribing to a Code of Professional Conduct
Organization administering
Code of Professional Conduct:
Address:
Telephone No.:
2. I,
, confirm that an environmental remedial action as
that term is defined in Section 3(2) of Chapter 308, Laws of 1998, is to be conducted on the following property:
Address
City
County
Property Tax Parcel Number
Under penalty of perjury under the laws of the State of Washington and other penalties prescribed by law,
I certify that the foregoing information is true and correct.
Signature
Print Name
Title
Date and Place
Address
Phone Number
City, State, Zip Code
Submit one copy of this certification to each agency listed below.
State of Washington, Department of Ecology
State of Washington, Department of Revenue
Attn: Notice of Environmental Remedial Action
Taxpayer Account Administration
Toxics Cleanup Program
Micrographics
PO Box 47600
PO Box 47476
Olympia, WA 98504-7600
Olympia, WA 98504-7476
(800) 826-7716, TTY (360) 407-6006
(800) 647-7706, TTY (800) 451-7985
To inquire about the availability of this document in an alternate format for the visually impaired or a language other than English,
please call (360) 753-3217. Teletype (TTY) users may call (800) 451-7985. You may also access tax information on our Internet home
page at
REV 41 0061 (6-08-98)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go