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Section 1: General Comment_

§ 4-417 Environment Article, Annotated Code of Maryland

(c) False statements in required documents; tampering with monitoring devices. Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this title, or by any permit, rule, regulation or order issued under this title, or who falsifies, tampers with, or knowingly renders inaccurate any monitoring device or method required to be maintained under this title or by any permit, rule, regulation, or order issued under this title, upon conviction, is subject to a fine not exceeding $10,000, or by imprisonment not exceeding six months or both.

Certified Inspector: (print) Company: Certification No.: Expiration. Date: Telephone No.: Facsimile No.: E-mail address:

*”High Risk Groundwater Use Area” (HRGUA) means all areas served by individual wells. Existing UST systems installed prior to 1/26/05 in Baltimore, Carroll, Cecil, Frederick and Harford counties or New UST systems installed after 1/26/05 in Anne Arundel, Baltimore, Carroll, Cecil, Charles, Calvert, Frederick, Harford, Howard, Montgomery, and Prince George’s counties.

The MDE UST database will be updated with information listed in this inspection report and any amended facility registration form unless additional forms are required by regulation.

Certified Inspector:

Owner/Operator or Designated Representative

I, the Maryland Certified Inspector, have performed this UST Inspection and believe the contents of this report to be true and accurate without misrepresentation or falsification. As well, I have no

I, the Owner/Operator/Designated Representative (circle one), have read this Inspection Report and understand the condition of my UST facility, including all deficiencies, corrections, and

financial interest with this UST Facility.

recommendations. Title: ______________________________________ Print Name:

Print Name:

________________________________ Signature: _________________________________ Date: _____________________________________

_________________________________ Signature: __________________________________ Date: ______________________________________

Mail REPORT To:

MDE Oil Control Program Suite 620 1800 Washington Blvd. Baltimore MD 21230-1719

Questions? Call MDE Oil Control Program at 410-537-3442 See our web page at:

http://www.mde.state.md.us

MDE Use Only Certification Section – Reviewed By __________________________ Date Reviewed ______________________ Pass______ Fail______

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________________________________________________________ Data Clerk’s Initials _________ Date Entered ___________________

Form Number: MDE/WAS/COM.055 Date: April 3, 2007 TTY Users: 800-735-2258

Facility I.D.

______________________

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