Form LW-904E "Installer Specialist Application Form" - New Mexico

What Is Form LW-904E?

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 October 27, 2016;
  • 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 LW-904E 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-904E "Installer Specialist Application Form" - New Mexico

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State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Installer Specialist 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”
Name of Applicant for Installer
Specialist
Name of Company
Mailing Address
Phone Number
Email Address
CID Licensure
Which CID License(s) do you
MM-1
MM-98
MS-1
MS-3
Expiration Date:
________/________/________
currently hold?
Professional Experience
1.
Do you have at least 3 years of professional experience installing on-site liquid waste systems in NM?
YES
NO
2.
Have you installed or repaired at least 100 on-site liquid waste systems in NM in accordance with permits
YES
NO
approved by NMED or Bernalillo County?
3.
Are you certified as an installer by a national industry or trade organization and have you installed at least
YES
NO
50 on-site liquid waste systems in NM in accordance with permits approved by NM or Bernalillo County?
Approved Continuing Education Units and NMED Regulations Training Class and Exam
1.
Have you complete 16 hours of training credits approved by NMED for this Installer Specialist category
YES
NO
within the past 3 years? (
Note: Training CEUs must be approved by NMED to meet KSAs for this category of certification)
2.
Have you completed an NMED Liquid Waste Regulation training class and passed an exam?
YES
NO
Compliance and Criminal Convictions
1.
Have you been issued any Compliance Orders within the past 3 years for violation of any provision of the
YES
NO
Liquid Waste Regulations 20.7.3 NMAC?
2.
Have you had any criminal convictions pursuant to NMSA 1978, Section 74-1-10 within the past five years
YES
NO
for violation of any provision of the Liquid Waste Regulations 20.7.3 NMAC?
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 working as an Installer Specialist. By signing below, I agree that the foregoing
information is true and correct.
_________________________________________ ________________________________________ _____________________
Installer Specialist Name Printed
Installer Specialist Signature
Date
Installer Specialist Application Submittal Requirements
[ ] Installer Specialist Application Form- Completed and signed
[ ] Copy of CID License – must be current and valid
[ ] Professional Experience – attach a letter which describes your professional experience; this should include how many years you
have been installing on-site liquid waste systems and approximately how many permit approvals you have received from that
state of New Mexico or Bernalillo County
[ ] NMED Liquid Waste Regulations Training and Exam- letter from NMED stating that you have attended the Liquid Waste
Regulation 20.7.3 NMAC Training and have passed the exam
[ ] Copy of CEU Certificate showing 16 hours of approved Installer Specialist CEUs have been completed within the past 3 years.
You must include documentation that allows NMED to make determination as whether these CEUs meet KSAs for this category
of certification
Please Send your complete application with attachments to:
Michael Broussard, EHB Liquid Waste Specialist, 2540 Camino Edward Ortiz, Santa Fe, NM 87505; Fax
505-827-1839 For more information please contact Michael Broussard at
Michael.Broussard@state.nm.us
or
505-476-0125
LW-904E (Revised 10-27-16)
State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Installer Specialist 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”
Name of Applicant for Installer
Specialist
Name of Company
Mailing Address
Phone Number
Email Address
CID Licensure
Which CID License(s) do you
MM-1
MM-98
MS-1
MS-3
Expiration Date:
________/________/________
currently hold?
Professional Experience
1.
Do you have at least 3 years of professional experience installing on-site liquid waste systems in NM?
YES
NO
2.
Have you installed or repaired at least 100 on-site liquid waste systems in NM in accordance with permits
YES
NO
approved by NMED or Bernalillo County?
3.
Are you certified as an installer by a national industry or trade organization and have you installed at least
YES
NO
50 on-site liquid waste systems in NM in accordance with permits approved by NM or Bernalillo County?
Approved Continuing Education Units and NMED Regulations Training Class and Exam
1.
Have you complete 16 hours of training credits approved by NMED for this Installer Specialist category
YES
NO
within the past 3 years? (
Note: Training CEUs must be approved by NMED to meet KSAs for this category of certification)
2.
Have you completed an NMED Liquid Waste Regulation training class and passed an exam?
YES
NO
Compliance and Criminal Convictions
1.
Have you been issued any Compliance Orders within the past 3 years for violation of any provision of the
YES
NO
Liquid Waste Regulations 20.7.3 NMAC?
2.
Have you had any criminal convictions pursuant to NMSA 1978, Section 74-1-10 within the past five years
YES
NO
for violation of any provision of the Liquid Waste Regulations 20.7.3 NMAC?
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 working as an Installer Specialist. By signing below, I agree that the foregoing
information is true and correct.
_________________________________________ ________________________________________ _____________________
Installer Specialist Name Printed
Installer Specialist Signature
Date
Installer Specialist Application Submittal Requirements
[ ] Installer Specialist Application Form- Completed and signed
[ ] Copy of CID License – must be current and valid
[ ] Professional Experience – attach a letter which describes your professional experience; this should include how many years you
have been installing on-site liquid waste systems and approximately how many permit approvals you have received from that
state of New Mexico or Bernalillo County
[ ] NMED Liquid Waste Regulations Training and Exam- letter from NMED stating that you have attended the Liquid Waste
Regulation 20.7.3 NMAC Training and have passed the exam
[ ] Copy of CEU Certificate showing 16 hours of approved Installer Specialist CEUs have been completed within the past 3 years.
You must include documentation that allows NMED to make determination as whether these CEUs meet KSAs for this category
of certification
Please Send your complete application with attachments to:
Michael Broussard, EHB Liquid Waste Specialist, 2540 Camino Edward Ortiz, Santa Fe, NM 87505; Fax
505-827-1839 For more information please contact Michael Broussard at
Michael.Broussard@state.nm.us
or
505-476-0125
LW-904E (Revised 10-27-16)