Free 53316.pdf - Indiana

APPLICATION FOR LISTING AS A QUALIFIED INSPECTOR FOR DRUG LAB CLEANUP
State Form 53316 (6-07)

Indiana Department of Environmental Management

INSTRUCTIONS:

1. A person who applies to be listed by IDEM as a qualified inspector may use this form to apply for listing as a Qualified Inspector to inspect and clean properties contaminated with chemicals used in the illegal manufacture of a controlled substance (illegal drug labs). 2. Print or type all requested information. 3. When completed, attach all required documentation and mail the package to IDEM Office of Land Quality, Qualified Inspector Listing MC 66-30,100 North Senate Avenue, Indianapolis, Indiana 46204-2251. You may also deliver the package to the IDEM Office of Land Quality, 100 North Senate Avenue, 11th Floor West, Indianapolis, Indiana. 4. For more information, contact IDEM's Office of Land Quality at (317) 233-1655.

Applicant information:
Name Address City Telephone Email address State Facsimile Zip Code

Employed by or doing business as if different from above:
Name Address City Telephone Email address Website URL State Facsimile Zip Code

Applicant's certification: I certify, under penalty of perjury as provided in IC 35-44-2-1, that to the best of my knowledge all information provided in this application is true and accurate. Signature of applicant: Date of application:

Attach all documents listed on reverse

Attachments Attach all of the following documents to this application. Documentation of 40 hours experience. This may include any of the following: 1) Copies of time sheets, job reports, etc. describing the type of job(s) worked on and the number of hours worked, with a statement that the job(s) were regulated under 29 CFR 1910.120. 2) Letter(s) from employer describing the type of job(s) worked on and the number of hours worked, with a statement that the job(s) were regulated under 29 CFR 1910.120. 3) An affidavit from applicant describing the type of job(s) worked on and the number of hours worked, with a statement that the job(s) were regulated under 29 CFR 1910.120. Verified: Date: _______________ Initial: _______________ Documentation of 29 CFR 1910.120(e) supervisor training. Attach a copy of the certificates you received from both of the following: 40-hour HAZWOPER training (29 CFR 1910.120(e)(3)) including 3 days of supervised field experience. 8 hours specialized management and supervisor training (29 CFR 1910.120(e)(4)). By: _________________ Documentation of IDEM qualified inspector training. Attach a copy of the certificate you received at the training class. Training date: __________ Exam score: ________ % Proof of Insurance: Attach documentation from your insurance carrier. Professional liability insurance ($1,000,000). Errors and omissions insurance ($1,000,000) Pollution prevention insurance ($3,000,000) Verified: Date: _______________ Initial: _______________ Please attach a business card or show how you want to appear on the qualified inspector list. Verified: Date: _______________ for IDEM use only