Form LW-904A "Third Party Evaluator Application Form" - New Mexico

What Is Form LW-904A?

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 March 16, 2015;
  • 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 fillable version of Form LW-904A by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW-904A "Third Party Evaluator Application Form" - New Mexico

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State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Third Party Evaluator Application Form
You must submit this completed application form along with all required documentation listed on the bottom of this page for your application to be deemed
“complete”
NOTE: This application is required for any third party evaluators who do not meet the qualification requirements under
Section 903(B)(2)(a)-(e), and who are seeking qualification under Section 903(B)(2)(f) of the New Mexico Liquid Waste
Disposal and Treatment Regulations 20.7.3 NMAC.
If you are a CID licensed contractor with an MM-1, MM-98, MS-1 or MS-3 license you do not need to submit an
application. If you are PE, RS, REHS, accredited by NSF or a NEHA installer you do not need to fill out this application.
Name of Applicant
Name of Company
Mailing Address
Phone Number
Email Address
Professional Experience
1.
Do you have at least 3 years of professional experience inspecting and evaluating onsite liquid waste
YES
NO
systems in New Mexico?
2.
Are you currently certified by the National Association of Wastewater Technicians (NAWT) as an
YES
NO
Inspector?
3.
What date does your Current NAWT certification expire?
_____/_____/_____
4.
How long have you been certified by the National Association of Wastewater Technicians (NAWT) as
________ Years
an inspector?
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 Third Party Evaluator. By signing below, I agree that the foregoing
information is true and correct.
I understand that I cannot make repairs to this system, install risers, install effluent filters or
do any other work which is beyond the scope of work which requires a CID license. I understand that if I should perform any
of this work without the appropriate CID license, this Third Party Evaluator certification will be revoked by NMED and a
letter will be sent to NAWT informing them of this revocation.
I understand that I cannot perform evaluations on advanced
treatment systems or unpermitted systems. I also understand that it is my responsibility to submit my NAWT renewal
certifications to NMED prior to the expiration of my certification.
_________________________________________ ________________________________________ _____________________
Third Party Evaluator Name Printed
Third Party Evaluator Signature
Date
Third Party Evaluator Application Submittal Requirements
[ ] Third Party Evaluator Application Form- Completed and signed
[ ] Copy of NAWT Inspector Certification – must be current and valid
[ ] Professional Experience – attach a letter which describes your professional experience; this should include how many years you
have been inspecting and evaluating on-site liquid waste systems in New Mexico
[ ] Attach copies of 3 Property Transfer Evaluations/Inspections that you have completed. Submit one evaluation form from
each of the years that you have been conducting these evaluations/inspections. These evaluation/inspection forms must
have your signature on them as the evaluator/inspector.
Please send your complete application to:
Michael Broussard, EHB Liquid Waste Specialist, 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
LW-904A (Revised 3-16-15)
State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Third Party Evaluator Application Form
You must submit this completed application form along with all required documentation listed on the bottom of this page for your application to be deemed
“complete”
NOTE: This application is required for any third party evaluators who do not meet the qualification requirements under
Section 903(B)(2)(a)-(e), and who are seeking qualification under Section 903(B)(2)(f) of the New Mexico Liquid Waste
Disposal and Treatment Regulations 20.7.3 NMAC.
If you are a CID licensed contractor with an MM-1, MM-98, MS-1 or MS-3 license you do not need to submit an
application. If you are PE, RS, REHS, accredited by NSF or a NEHA installer you do not need to fill out this application.
Name of Applicant
Name of Company
Mailing Address
Phone Number
Email Address
Professional Experience
1.
Do you have at least 3 years of professional experience inspecting and evaluating onsite liquid waste
YES
NO
systems in New Mexico?
2.
Are you currently certified by the National Association of Wastewater Technicians (NAWT) as an
YES
NO
Inspector?
3.
What date does your Current NAWT certification expire?
_____/_____/_____
4.
How long have you been certified by the National Association of Wastewater Technicians (NAWT) as
________ Years
an inspector?
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 Third Party Evaluator. By signing below, I agree that the foregoing
information is true and correct.
I understand that I cannot make repairs to this system, install risers, install effluent filters or
do any other work which is beyond the scope of work which requires a CID license. I understand that if I should perform any
of this work without the appropriate CID license, this Third Party Evaluator certification will be revoked by NMED and a
letter will be sent to NAWT informing them of this revocation.
I understand that I cannot perform evaluations on advanced
treatment systems or unpermitted systems. I also understand that it is my responsibility to submit my NAWT renewal
certifications to NMED prior to the expiration of my certification.
_________________________________________ ________________________________________ _____________________
Third Party Evaluator Name Printed
Third Party Evaluator Signature
Date
Third Party Evaluator Application Submittal Requirements
[ ] Third Party Evaluator Application Form- Completed and signed
[ ] Copy of NAWT Inspector Certification – must be current and valid
[ ] Professional Experience – attach a letter which describes your professional experience; this should include how many years you
have been inspecting and evaluating on-site liquid waste systems in New Mexico
[ ] Attach copies of 3 Property Transfer Evaluations/Inspections that you have completed. Submit one evaluation form from
each of the years that you have been conducting these evaluations/inspections. These evaluation/inspection forms must
have your signature on them as the evaluator/inspector.
Please send your complete application to:
Michael Broussard, EHB Liquid Waste Specialist, 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
LW-904A (Revised 3-16-15)