Form LW904D "Septage Pumper Qualification Certificate Application for Registration" - New Mexico

What Is Form LW904D?

This is a legal form that was released by the New Mexico Environment Department - a government authority operating within New Mexico. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the New Mexico Environment Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LW904D by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW904D "Septage Pumper Qualification Certificate Application for Registration" - New Mexico

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Septage Pumper Qualification Certificate
New Mexico Environment Department
Application for Registration
Environmental Health Bureau
Liquid Waste Program
Applicant Information
Name of Applicant (Last, First)
Name of Company
Mailing Address
Company Mailing Address
City, State
Zip
City, State,
Zip
Phone Number
Company Contact Name and Phone Number:
Email Address
Company Email Address
Physical Address where vacuum trucks are stored:
Have you completed the NAWT Vacuum Truck Technician Training Certification Program or a
YES
NO
comparable program?
You must demonstrate familiarity with the applicable regulations and demonstrate competence in locating and exposing septic tanks, measuring
septic sludge and scum levels, the complete pumping of septic tank sludge, maintenance of pumping equipment in a sanitary condition and
prevention of pathogen transmission and preparation of an appropriate safety plan for normal operations. NMED considers completion of the
National Association of Wastewater Technicians (NAWT) Vacuum Truck Technician Training (VTT) Certification Program as demonstrating
http://www.nawt.org
competence for these requirements. For classroom training dates or online training call 1-800-236-6298 or go to
Do you understand that you must maintain your equipment to ensure no sewage spill occurs during transport or
storage and that your employees or the public are not subject to a hazard to public health?
YES
NO
Do you have a written contingency plan for spill abatement and shall have the equipment and supplies needed
to abate spills onsite during each pumping operation?
YES
NO
Do you understand that there must be a Certified Septage Pumper on-site any time that a septic tank is pumped
and anytime septage is transported and disposed of?
YES
NO
List all the facilities that you use for the septage disposal. Upon request you may be asked to provide copies of
any permits or licenses issued by the owner of the disposal facility to the septage
Septage Disposal Facilities that I use (list name of facility, address, location, and contact name and phone #):
By signing below, I acknowledge that I have read the Liquid Waste Disposal and Treatment Regulations and I
understand the sections of the regulations that pertain to working as a septage pumper.
Septage Pumper Signature
Date
Septage Pumper Name Printed
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
☐ Septage Pumper Qualification Certificate $30
Total Fee Paid
Check number
Date Paid
Payment Received By
Please Complete this Application and
attach your NAWT Vacuum Truck Technician Training Certification
and Send to : Michael
Broussard, EHB Liquid Waste Program, 2540 Camino Edward Ortiz, Santa Fe, NM 87507; Fax 505-827-1839 For more information
please contact Michael Broussard at
Michael.Broussard@state.nm.us
or 505-476-9125
Once you are registered with NMED your name will be added to the Approved Septage Pumper list on the Liquid Waste Program’s website
Please note that the certificate of registration belongs ONLY to the trained applicant as approved and registered. It does not belong to the
company. The company name is associated with our records for administrative purposes. A trained and registered individual must be at
the site of any pumping activity as well as on the truck during transport and disposal.
☐ Approved
☐ Denied
☐ Incomplete
Septage Pumper Registration
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW904D 200701
Septage Pumper Qualification Certificate
New Mexico Environment Department
Application for Registration
Environmental Health Bureau
Liquid Waste Program
Applicant Information
Name of Applicant (Last, First)
Name of Company
Mailing Address
Company Mailing Address
City, State
Zip
City, State,
Zip
Phone Number
Company Contact Name and Phone Number:
Email Address
Company Email Address
Physical Address where vacuum trucks are stored:
Have you completed the NAWT Vacuum Truck Technician Training Certification Program or a
YES
NO
comparable program?
You must demonstrate familiarity with the applicable regulations and demonstrate competence in locating and exposing septic tanks, measuring
septic sludge and scum levels, the complete pumping of septic tank sludge, maintenance of pumping equipment in a sanitary condition and
prevention of pathogen transmission and preparation of an appropriate safety plan for normal operations. NMED considers completion of the
National Association of Wastewater Technicians (NAWT) Vacuum Truck Technician Training (VTT) Certification Program as demonstrating
http://www.nawt.org
competence for these requirements. For classroom training dates or online training call 1-800-236-6298 or go to
Do you understand that you must maintain your equipment to ensure no sewage spill occurs during transport or
storage and that your employees or the public are not subject to a hazard to public health?
YES
NO
Do you have a written contingency plan for spill abatement and shall have the equipment and supplies needed
to abate spills onsite during each pumping operation?
YES
NO
Do you understand that there must be a Certified Septage Pumper on-site any time that a septic tank is pumped
and anytime septage is transported and disposed of?
YES
NO
List all the facilities that you use for the septage disposal. Upon request you may be asked to provide copies of
any permits or licenses issued by the owner of the disposal facility to the septage
Septage Disposal Facilities that I use (list name of facility, address, location, and contact name and phone #):
By signing below, I acknowledge that I have read the Liquid Waste Disposal and Treatment Regulations and I
understand the sections of the regulations that pertain to working as a septage pumper.
Septage Pumper Signature
Date
Septage Pumper Name Printed
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
☐ Septage Pumper Qualification Certificate $30
Total Fee Paid
Check number
Date Paid
Payment Received By
Please Complete this Application and
attach your NAWT Vacuum Truck Technician Training Certification
and Send to : Michael
Broussard, EHB Liquid Waste Program, 2540 Camino Edward Ortiz, Santa Fe, NM 87507; Fax 505-827-1839 For more information
please contact Michael Broussard at
Michael.Broussard@state.nm.us
or 505-476-9125
Once you are registered with NMED your name will be added to the Approved Septage Pumper list on the Liquid Waste Program’s website
Please note that the certificate of registration belongs ONLY to the trained applicant as approved and registered. It does not belong to the
company. The company name is associated with our records for administrative purposes. A trained and registered individual must be at
the site of any pumping activity as well as on the truck during transport and disposal.
☐ Approved
☐ Denied
☐ Incomplete
Septage Pumper Registration
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW904D 200701

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