ADEM Form 12 "Solid Waste Landfill Operator Reciprocal Certification Application" - Alabama

What Is ADEM Form 12?

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

Form Details:

  • Released on January 1, 2010;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • 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 fillable version of ADEM Form 12 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

ADVERTISEMENT
ADVERTISEMENT

Download ADEM Form 12 "Solid Waste Landfill Operator Reciprocal Certification Application" - Alabama

Download PDF

Fill PDF online

Rate (4.6 / 5) 64 votes
State of Alabama
ADEM USE ONLY
Solid Waste Landfill Operator
Approved ____Rejected_____
Reciprocal Certification Application
Reviewed By ________________
ADEM Form 12
Applicant # _________________
Please read instructions before completing this application. Type or Print in black ink.
1. APPLICANT INFORMATION:
Mr. ( )
Name: Ms. ( )
Mrs. ( ) ______________________________________________________________________________
(First)
(Middle)
(Last)
(Jr., Sr., III, etc.)
Address: ____________________________________________________________________________________
(Number and Street)
(Home Telephone)
____________________________________________________________________________________________
(City)
(State)
(Zip)
(Work Telephone)
*Social Security Number: _______________________E-mail address ____________________________________
*
Social Security Numbers are used only for the purpose of recordkeeping in accordance with Sec. 7(a)(2)(a) of P.L. 93-579*
2. EMPLOYED BY:
Landfill Name:
___________________
Permit #
__________________
Not Currently Employed by a Landfill: ________
3. HIGH SCHOOL DIPLOMA:
School and Year of Graduation:
_____________________________________________________
If GED, List Date Received :
______________________________________________________
4. CURRENT CERTIFICATION HELD:
STATE: ___________________________________
Expiration Date ____________________
ADEM Form 12 01/10
State of Alabama
ADEM USE ONLY
Solid Waste Landfill Operator
Approved ____Rejected_____
Reciprocal Certification Application
Reviewed By ________________
ADEM Form 12
Applicant # _________________
Please read instructions before completing this application. Type or Print in black ink.
1. APPLICANT INFORMATION:
Mr. ( )
Name: Ms. ( )
Mrs. ( ) ______________________________________________________________________________
(First)
(Middle)
(Last)
(Jr., Sr., III, etc.)
Address: ____________________________________________________________________________________
(Number and Street)
(Home Telephone)
____________________________________________________________________________________________
(City)
(State)
(Zip)
(Work Telephone)
*Social Security Number: _______________________E-mail address ____________________________________
*
Social Security Numbers are used only for the purpose of recordkeeping in accordance with Sec. 7(a)(2)(a) of P.L. 93-579*
2. EMPLOYED BY:
Landfill Name:
___________________
Permit #
__________________
Not Currently Employed by a Landfill: ________
3. HIGH SCHOOL DIPLOMA:
School and Year of Graduation:
_____________________________________________________
If GED, List Date Received :
______________________________________________________
4. CURRENT CERTIFICATION HELD:
STATE: ___________________________________
Expiration Date ____________________
ADEM Form 12 01/10
5.
EXPERIENCE: (If your experience record is from more than two facilities please copy this portion of the application and
submit additional pages as needed)
Landfill Name: ___________________________________________________________
Facility /Permit #: ________________
Address: _________________________________________________________________ City/State: ______________________
Type (MSW/IND/C&D): ________ Dates of Employment: From :_____________________ To: __________________________
(month and year)
(month and year)
Total Months: ________ Full Time
Part Time
Number of Hours Per Week: ________
Duties and Responsibilities:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Attach additional sheet if needed.)
Landfill Name: ___________________________________________________________
Facility /Permit #: ________________
Address: _________________________________________________________________ City/State: ______________________
Type (MSW/IND/C&D): ________ Dates of Employment: From :_____________________ To: __________________________
(month and year)
(month and year)
Total Months: ________ Full Time
Part Time
Number of Hours Per Week: ________
Duties and Responsibilities:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Attach additional sheet if needed.)
6. APPLICATION VERIFICATION:
I, the undersigned, do hereby affirm and swear, under oath, that I am the said applicant; that all statements made and infor-
mation contained in this application are true and correct to the best of my knowledge and belief. I understand that falsification of
statements or supporting data may result in denial of this application or suspension/revocation of any certificate I may hold. Further,
I understand that it is my responsibility to provide documentation upon request of any claims on this form and provide supplemental
material to reflect any material change in circumstances which may affect my eligibility for certification.
Signature of Applicant: ___________________________________________________________
Date signed:
___________________________________________________________
**NOTICE**
Before mailing, please be sure that you have completed the application in its entirety. Please see ADEM Administrrative Code R.
335-1-6 Schedule G for applicable fees (Checks or money orders only). Faxed applications are not accepted. Information recorded
on this form will be verified by contacting the certification authorities in the state where current certificate is held. For more
information reference ADEM Administrative Code R. 335-13-12. Mail application with appropriate fee to:
Operator Certification Section
Alabama Department of Environmental Management
Post Office Box 301463
Montgomery, Alabama 36130-1463
Visit our website at www.adem.state.al.us
ADEM Form 12 01/10
Page of 2