ADEM Form 11 "Solid Waste Landfill Operator Initial Certification Application" - Alabama

What Is ADEM Form 11?

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 11 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 11 "Solid Waste Landfill Operator Initial Certification Application" - Alabama

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State of Alabama
ADEM USE ONLY
Solid Waste Landfill Operator
Approved ____Rejected_____
Initial Certification Application
Reviewed By ________________
MOLO # _________________
ADEM Form 11
Please read instructions before completing this application. Type or Print in black ink.
APPLICANT INFORMATION:
Mr. ( )
Name: Ms. ( )
Mrs. ( ) __________________________________________________________________________________________
(First)
(Middle)
(Last)
(Jr., Sr., III, etc.)
Address: ________________________________________________________________________________________________
(Number and Street)
(Home Telephone)
________________________________________________________________________________________________________
(City)
(State)
(Zip)
(Work Telephone)
MOLO # (if applicable): _________________
High School and Year of Graduation or GED: _________________________
*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*
EXPERIENCE: (Please submit a separate form for each facility where experience was gained)
Landfill Name: ______________________________________________________
Facility/Permit # :_____________________
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.)
DOCUMENTATION OF TRAINING: (Please list all approved training hours along with a course description and dates:)
COURSE NAME*
INSTRUCTOR
DATES TAKEN
HOURS COMPLETED
*Attach additional sheets if necessary
I, the undersigned, do hereby affirm and swear, under oath, that I am the said applicant; that all statements made and information 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 re-
sponsibility 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: ____________________
ADEM Form 11 01/10
State of Alabama
ADEM USE ONLY
Solid Waste Landfill Operator
Approved ____Rejected_____
Initial Certification Application
Reviewed By ________________
MOLO # _________________
ADEM Form 11
Please read instructions before completing this application. Type or Print in black ink.
APPLICANT INFORMATION:
Mr. ( )
Name: Ms. ( )
Mrs. ( ) __________________________________________________________________________________________
(First)
(Middle)
(Last)
(Jr., Sr., III, etc.)
Address: ________________________________________________________________________________________________
(Number and Street)
(Home Telephone)
________________________________________________________________________________________________________
(City)
(State)
(Zip)
(Work Telephone)
MOLO # (if applicable): _________________
High School and Year of Graduation or GED: _________________________
*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*
EXPERIENCE: (Please submit a separate form for each facility where experience was gained)
Landfill Name: ______________________________________________________
Facility/Permit # :_____________________
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.)
DOCUMENTATION OF TRAINING: (Please list all approved training hours along with a course description and dates:)
COURSE NAME*
INSTRUCTOR
DATES TAKEN
HOURS COMPLETED
*Attach additional sheets if necessary
I, the undersigned, do hereby affirm and swear, under oath, that I am the said applicant; that all statements made and information 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 re-
sponsibility 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: ____________________
ADEM Form 11 01/10
EXPERIENCE VERIFICATION: (This section should be filled out by person who is verifying experience of applicant.)
Do you concur with the above applicant’s duties and responsibilities and time of experience?
YES
NO
My contacts with the applicant were during the period of time from ________________________to ________________________
where I was employed with _________________________________________________ Facility/Permit #: __________________
As the applicant’s supervisor
As the applicant’s associate employed at the same facility
If neither of the above is the case, please state basis of contact ________________________________________________________
Comments: ________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Attach additional sheet if needed)
In view of my knowledge of the applicant and his/her abilities, I __________ recommend the applicant for Certified Operator status.
(do, do not)
Print Name:_______________________________________
Present Position: _____________________________________ Employer: _____________________________________________
Address: ___________________________________________________________________________________________________
Daytime Phone Number: _______________________
I, the undersigned, do hereby affirm and swear, under oath, that all statements made and information contained in this form are true
and correct to the best of my knowledge and belief. I understand that falsification of statements or supporting data may result in de-
nial of this application or suspension/revocation of any certificate I may hold.
Signature: ________________________________________________ Date: _________________________________________
**NOTICE TO APPLICANT**
Before mailing please be sure that the application is completed in its entirety. Please see ADEM Administrative Code R. 335-1-6
Schedule G for applicable fees (Checks or money orders only). Faxed applications are not accepted. For more information refer-
ence 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 11 01/10
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