Dhec Certificate Of Financial Responsibility Page 3

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Underground Storage Tank (UST)
Certificate of Financial Responsibility
2600 Bull Street, Columbia, SC 29201-1708
Date Received
Complete and return original form to the Department.
Keep one copy at your UST facility.
Submit completed form to:
UST Financial Responsibility Liaison
SC Department of Health and Environmental Control
2600 Bull Street
Columbia, South Carolina 29201-1708
State Use Only
Telephone (803) 898-0589
Fax (803) 898-0673
I.
TANK OWNER
TANK OPERATOR
(Corporation, Individual, Public Agency, Other)
Mailing Address
City
State
Zip Code
Area Code
Telephone Number
Contact Person
o
II.
SITE IDENTIFICATION AND LOCATION (check here if USTs are newly-installed)
Permit # (UST Site ID #)
Facility Name or Company Site Identifier
Physical Street Address or State Road (as applicable)
City
State
Zip
County
DHEC 3472 (06/2013)
(over)

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