Free 53785.xls - Indiana

APPLICATION for WASTEWATER TREATMENT PLANT APPRENTICE to REQUEST CERTIFICATION
State Form 53785 (11-08) Reset Form Approved by State Board of Accounts, 2008 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Pursuant to 327 IAC 5-22 NOTE: A $30.00 FEE MUST BE SUBMITTED WITH EACH CERTIFICATION APPLICATION. FAILURE TO FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN THE APPLICATION BEING DISAPPROVED. (APPLICATION FEE IS NONREFUNDABLE.) Apprentice Card Number: Certification requested: (check one ) Expiration date (month, day, year ): Municipal: Industrial: I-SP A-SO I A B II C III D IV

FOR OFFICE USE Classification Status

Remarks

I. GENERAL INFORMATION FOR ALL APPLICANTS (please type or print legibly )
A. Name of applicant (last, first, middle ) Mr. Miss Mrs. Ms. B. Mailing Address (number and street ): City: Office telephone number: ( ) C. Date of birth (month, day, year ): State: ZIP code: County: Fax number: ( )

Home telephone number: ( ) E-mail address:

D. Have you ever applied for wastewater certification in Indiana before? Yes No F.Have you ever been the subject of a wastewater license suspension or revocation proceeding or investigation? Yes No

E. Are you presently a certified operator in Indiana? Yes No Certification Number: Expiration Date: G. If yes, list the date and the result of the investigation or proceeding. Attach additional sheets if necessary.

II. EDUCATION AND TRAINING-Must be completed for certification applicants. List below all high schools and post high schools attended.
Name/Location of School High Sch. Grad? Yes No College Grad? Yes No Other: If you are applying for Class IV / Class D certification, original transcripts must be enclosed. For the consideration of using college education to substitute for work experience, original college transcripts must be enclosed. If you would like to have your original transcripts returned, please check the box and enclose a self-addressed, stamped envelope. From (Month/Year ) To (Month/Year ) Diploma (GED) or Type of Degree and Date of Graduation

Continuing Education completed which is relevant to Certification:
Title of Specialized Training or Class Company/School Attended Dates Attended (month, day, year ) Credits or Contact Hours1 earned:

Copies of credit report forms (and in the case of on-line courses, certificates of completion) must be enclosed.
1

"Contact Hour" means a fifty (50) to sixty (60) minute instructional session, approved by the Commissioner and involving a qualified instructor or lecturer. Ten (10) contact hours equals one (1) continuing education unit (CEU).

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III. OPERATIONAL EXPERIENCE HISTORY-Must be completed for certification applicants List your current assignment first. Show all acceptable experience in wastewater treatment plants. "Acceptable experience" means employment in the actual hands-on operation, maintenance, management, or supervision of a wastewater treatment plant. Acceptable experience shall be obtained under the supervision of a certified operator or by otherwise demonstrating that your experience meets the requirements. Date (Month/Year ) From: To: Position Title Name of Facility

Position Information
Class of Facility Type of Treatment/Average Flow Location (City & State ) of Facility NPDES Permit Number

Hours Per Week Cert.Op.in Responsible Charge/Facility

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

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IV. RESPONSIBLE CHARGE EXPERIENCE
(Must be completed by Class III, IV, C, and D certification applicants; optional for other classes) List specific duties for positions of responsible charge. "Responsible charge" means the certified operator who makes process control or system integrity decisions about the overall daily operation, maintenance, management, or supervision of a wastewater treatment plant necessary to meet the performance requirement and limits of the assigned permit and any applicable local ordinance or other regulatory requirements. In Class III, IV, C, or D plants, the individual supervising and responsible for a major section of the plant or an operating shift may be credited with responsible charge experience. Additional sheets may be attached, as necessary. Date (Month/Year ) From: To: Position Title Name of Facility

Position Information
Class of Facility Type of Treatment/Average Flow Location (City & State ) of Facility NPDES Permit Number

Hours Per Week Cert.Op.in Responsible Charge/Facility

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

Position Title

Name of Facility

Hours Per Week Cert.Op.in Responsible Charge/Facility

Class of Facility Type of Treatment/Average Flow

Location (City & State ) of Facility NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the supervision of a certified operator)

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V. SIGNATURE OF APPLICANT (Required)
I, the undersigned, certify that I am the above applicant; that all statements made and information regarding education, training, acceptable experience and responsible charge experience are true and correct to the best of my knowledge and belief; that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for, revocation of any certification granted or voiding a decision made regarding my application. I also consent to verification of my qualifications for the certificate for which I have applied. Date (month, day, year ) Signature of Applicant

VI. SIGNATURE OF APPLICANT'S SUPERVISOR (Required for certification applicants)
I, the undersigned, hereby certify the information contained in Sections II, III, and IV of this application is true and correct to the best of my knowledge.

I have supervised this individual for ____________ years. Signature of Supervisor Printed Name of Supervisor Name of Organization Address (number and street name, city, state, zip code ) Telephone number: Fax Number: Title

Date (month, day, year ) Wastewater Cert. Number, if applicable

The completed application, along with all required fees and attachments should be mailed to: Cashier Indiana Department of Environmental Management 100 N. Senate Ave - Mail Code 50-10C Indianapolis, IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management. DO NOT SEND CASH.

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