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Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | FOR OFFICE USE
 |  | APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR CERTIFICATION BY RECIPROCITY |  |  |  |  | Classification
 |  | State Form 47290 (R4 / 2-08) |  |  |  |  | Status
 |  | 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 APPLICATION FOR CERTIFICATION.  APPLICATIONS MUST BE SIGNED BY THE INDIVIDUAL AND HIS/HER SUPERVISOR.  FAILURE TO FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN THE APPLICATION BEING DISAPPROVED.  (APPLICATION FEE IS [NAME].)                                                                                  PLEASE SUBMIT A COPY OF YOUR CURRENT CERTIFICATION ALONG WITH THIS APPLICATION
 |  |  |  |  |  |  | Remarks:
This is an application for a Class: (check one)                                                                                 Industrial  o A-SO o A o B o C o D    Municipal  o I-SP o I o II o III o IV
Would you accept a lower classification if not eligible for Class checked above?
 |  |  |  |  | ¨ Yes      ¨ No
I. GENERAL INFORMATION (please type or print legibly)
A. Name of applicant (last, first, middle)
¨ Mr.   ¨ Miss   ¨ Mrs.   ¨ Ms.
B. Mailing Address (number and street):
City: |  |  | State: | ZIP code: | County:
Office telephone number: |  |  |  | Home telephone number:
(                     ) |  |  |  | (                     )
Fax number: |  |  |  | E-mail address:
(                     )
[NAME] of birth: (month,day,year) |  |  |  | D. Have you ever applied for wastewater certification in
 |  |  |  | Indiana before? |  | ¨ Yes      ¨ No
E. In which state are you presently a certified operator? |  |  |  | Certification Number: |  |  | Expiration Date: (month,day,year)
Did you obtain this certification by a written exam? |  |  |  | State Contact Person:
 |  | ¨ Yes      ¨ No
Mailing address (number and street): |  |  | City: |  | State: |  | ZIP code:
II. EDUCATION AND TRAINING
List below all high schools and post high schools attended.
 |  | Name/Location of School |  | From (Month/Year) | To (Month/Year) |  | [NAME] (GED) or Type of Degree and Date of Graduation
High Sch. Grad?
¨ Yes    ¨ No
[NAME]?
¨ Yes    ¨ No
Other:
Specialized Training or Classes Relevant to Certification
Title of Specialized Training or Class |  |  | Company/School Attended |  | [NAME] |  | Credits or Contact Hours1   earned:
Copies of credit report forms or proof of attendance 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).
III. OPERATIONAL EXPERIENCE HISTORY
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) |  | Position Information
From: | To:
 |  | Position Title | Name of Facility |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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)
IV. RESPONSIBLE CHARGE EXPERIENCE
(must be completed by Class III, IV, C, and D 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) |  | Position Information
From: | To:
 |  | Position Title | Name of Facility |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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 |  | Class of Facility | Location (City & State) of Facility
Hours Per Week |  | Cert.Op. in Responsible Charge of Facility |  | Type of Treatment/Average Flow |  | 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)
V. SIGNATURE OF APPLICANT
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.
Signature of applicant |  |  |  |  |  | Date (month, day, year)
VI. SIGNATURE OF APPLICANT'S SUPERVISOR
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 |  |  |  |  |  | Date (month, day, year)
Printed Name of Supervisor |  |  |  | Title |  | [NAME]. Number, if applicable
Name of Organization
Address (Number and Street Name, City, State, ZIP Code)
Telephone number:(         ) |  |  |  | Fax Number:(         )
The completed application, along with all required fees and attachments should be mailed to:
 | Indiana Department of Environmental Management
 | Cashier - Mail Code 50-10C
 | 100 N. Senate Ave
 | Indianapolis, IN  46204-2251
Please make all checks payable to the Indiana Department of Environmental Management.
DO NOT SEND CASH.