ADEM Form 13 "Solid Waste Landfill Operator Certification Renewal" - Alabama

What Is ADEM Form 13?

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 13 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 13 "Solid Waste Landfill Operator Certification Renewal" - Alabama

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ADEM USE ONLY
State of Alabama
Late Fee:
______________
Solid Waste Landfill Operator
Certification Renewal
Date Renewed:
______________
ADEM Form No. 13
Approved By:
______________
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)
________________________________________
(County)
*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*
FACILITY INFORMATION:
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:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
________________________________________________________________________________________________________
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 needed.)
ADEM Form 13 01/10
ADEM USE ONLY
State of Alabama
Late Fee:
______________
Solid Waste Landfill Operator
Certification Renewal
Date Renewed:
______________
ADEM Form No. 13
Approved By:
______________
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)
________________________________________
(County)
*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*
FACILITY INFORMATION:
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:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
________________________________________________________________________________________________________
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 needed.)
ADEM Form 13 01/10
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 license 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 licensure.
Signature of Applicant: ___________________________________________________________ Date: ___________________
Current Certification #: ___________________ Type (MSW, IND, C&D): __________ Expiration Date: _____________
**NOTICE TO APPLICANT**
Before mailing please be sure that the application is completed in its entirety. An application must be accompanied by a nonrefund-
able license fee. Please see ADEM Administrative Code R. 335-1-6 Schedule G for applicable fees (Checks or money orders only).
Make checks payable to ADEM. Please note, if a complete application is not received prior to the date of expiration, the late renewal
fee will be assessed. Faxed applications are not accepted. For more information reference ADEM Administrative Code R.
335-13-12. Mail application 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 13 01/10
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