Form LW-904C "Maintenance Service Provider Application Form" - New Mexico

What Is Form LW-904C?

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-904C 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-904C "Maintenance Service Provider Application Form" - New Mexico

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State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Maintenance Service Provider Application Form (Part A)
Name of Applicant for MSP
Name of Company
Mailing Address
Phone Number
Email Address
Certification by the Manufacturer
Which Certifications are
NM Operator Certification for Small Advanced Wastewater Systems (Or higher)
Current and Active?
Certification as Wastewater Operator from another state
(Attach all certifications with this
Other Certification based on Credentials Approved by the Department
application)
Name All Proprietary Advanced Treatment Systems
that you are applying for Qualification under 904(C)
of Liquid Waste Regulations 20.7.3 NMAC
(NOTE: You must submit a “PART B” for each and
every ATS that you are requesting approval to sesrvice)
For each of the Advanced Treatment Systems listed above, you must fill out a “ATS QUALIFICATION
YES
NO
FORM” Qualification Forms for each ATS are Attached?
Do you have the ability to sample all units using approved sampling methods?
YES
NO
Will you be able to respond to emergency situations within 48 hours of being notified?
YES
NO
Do you use a contract for service that contains, at least, minimum standards approved by NMED?
YES
NO
Do you have a quality assurance/quality control plan acceptable to the department?
YES
NO
Will you notify NMED within 5 working days for any failed system?
YES
NO
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 a maintenance service provider. I understand that should I be approved as
a maintenance service provider on specific advanced treatment units, that I must be on-site for all activities involving the
maintenance of these advanced treatment systems.
_________________________________________ ________________________________________ _____________________
MSP Name Printed
MSP Signature
Date
Please Complete this Application Form(Part A) along with Part B Forms for each ATS you want to work on 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
State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
LW-904C (Revised 10-27-16)
State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
Maintenance Service Provider Application Form (Part A)
Name of Applicant for MSP
Name of Company
Mailing Address
Phone Number
Email Address
Certification by the Manufacturer
Which Certifications are
NM Operator Certification for Small Advanced Wastewater Systems (Or higher)
Current and Active?
Certification as Wastewater Operator from another state
(Attach all certifications with this
Other Certification based on Credentials Approved by the Department
application)
Name All Proprietary Advanced Treatment Systems
that you are applying for Qualification under 904(C)
of Liquid Waste Regulations 20.7.3 NMAC
(NOTE: You must submit a “PART B” for each and
every ATS that you are requesting approval to sesrvice)
For each of the Advanced Treatment Systems listed above, you must fill out a “ATS QUALIFICATION
YES
NO
FORM” Qualification Forms for each ATS are Attached?
Do you have the ability to sample all units using approved sampling methods?
YES
NO
Will you be able to respond to emergency situations within 48 hours of being notified?
YES
NO
Do you use a contract for service that contains, at least, minimum standards approved by NMED?
YES
NO
Do you have a quality assurance/quality control plan acceptable to the department?
YES
NO
Will you notify NMED within 5 working days for any failed system?
YES
NO
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 a maintenance service provider. I understand that should I be approved as
a maintenance service provider on specific advanced treatment units, that I must be on-site for all activities involving the
maintenance of these advanced treatment systems.
_________________________________________ ________________________________________ _____________________
MSP Name Printed
MSP Signature
Date
Please Complete this Application Form(Part A) along with Part B Forms for each ATS you want to work on 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
State of New Mexico Environment Department
Environmental Health Bureau
Liquid Waste Program
LW-904C (Revised 10-27-16)
MSP Application-ATS Qualification Form (Part B)
You must submit a separate “Part B” for each type of advanced treatment system(ATS) that you are requesting t to service. Fill out
one form for each Manufacture and include all model numbers. The department will determine whether you meet the regulatory
requirements and will send you a letter informing you that you have been approved or denied for maintaining this system. For all
systems that you are approved to operate, service and maintain , your name will be listed on the NMED website.
1. Name of Advanced Treatment Unit(s) you are
requesting to inspect, operate and maintain
(Include Name of Manufacturer and Model Numbers)
YES
NO
1. Have you completed a training and certification
program from the manufacturer on this ATS?
Date of the last training you attended on this ATS?
_______/_______/_______
a. If You Answered YES to the question above
Please submit all certifications as part of this application
If You Answered NO to the question above
b.
3. You must provide a written statement that
describes trainings that you have received on similar
types of ATSs and describe your experience at
YES
NO
operating, maintaining and servicing these units. Is
this statement attached?
4. Do you have operation and maintenance manuals
for this ATS that would be made available for
YES
NO
NMED verification?
5. Do you have regular access to replacement parts for
YES
NO
this ATS?
6. If the operation and maintenance of this ATS requires
YES
NO
N/A
specialized tools, do you have access these tools?
By signing below, I agree that the foregoing information is true and correct to the best of my knowledge.
_________________________________________ ________________________________________ _____________________
MSP Name Printed
MSP Signature
Date
LW-904C (Revised 7-28-14)
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