State of Utah
For Official Use Only
Department of Environmental Quality
Division of Air Quality
ATLAS Section
th
195 North 1950 West, 4
Floor
P.O. Box 144820
Salt Lake City, Utah 84114-4820
Postmark Date: __________________ Initials: _______
asbestos@utah.gov
Check #/Credit Card Amount: _____________________
ASBESTOS INDIVIDUAL CERTIFICATION APPLICATION FORM
Please read the instructions at the end of this form prior to completion. Please complete all sections of
the form or write N/A. Improperly completed forms may be rejected delaying your application.
A. Individual Certification Information
Name of Individual: ___________________________________________________________________________________________
Individual’s Home Address: _____________________________________________________________________________________
 Check this box to send certifica-
Street Address, Suite #, or P.O. Box
City
State
Zip Code
tion card to home address otherwise
company address will be used
Date of Birth: ______________ Height: ____________ Weight: ____________ Hair Color: ____________ Eye Color: ____________
month/day/year
feet/inches
pounds
Individual Telephone # (____) ____ - ______ ext. ______ Individual FAX # (____) ____ - ______ Email: ________________________
Employing Company Name: ____________________________________________________________________________________
Employing Company Mailing Address: ____________________________________________________________________________
Street Address, Suite No./P.O. Box
City
State
Zip Code
Company Telephone # (____) ____ - ______ ext. ______ Company FAX # (____) ____ - ______ Email: ________________________
B. Type of Individual Certification
 Initial Individual Certification (Please check this box, complete, and submit the entire form)
 Individual Recertification #ASB - _______________ (Please check this box, complete, and submit the entire form)
 Lost Individual Certification Card #ASB - _______________ (Please check this box, complete, and submit the entire form)
C. Asbestos Individual Certification Application Fee
Please read the instructions on the last page prior to completing this section
Total Asbestos
Asbestos Individual Certification Application
Individual Certification Application Fees
Individual Certification
Disciplines, Fees, and Surcharges
and Surcharges
Application Fees
 Lost Certification Card Replacement Fee ($33.00)
 Lost Card Certification Card Replacement Fee
($33.00)
 Non-Utah Accredited Training Provider Surcharge ($33.00)
 Asbestos Inspector Initial Renewal
Non-Utah Accredited Training Provider Surcharge
Trainer/Cert.#__________________________________
 Asbestos Management Planner Initial Renewal
________________________ X $33.00/certificate
Trainer/Cert.#__________________________________
$ __________________
(Total number of non-Utah Training Provider Course Certificates)
 Project Designer Initial Renewal
Trainer/Cert.#__________________________________
Individual Certification Application Fees
 Asbestos Supervisor Initial Renewal
Trainer/Cert.#__________________________________
______________ X $137.50/year
 Asbestos Worker Initial Renewal
(Total number of Asbestos Discipline(s))
Trainer/Cert.#__________________________________
(1 year certification maximum per discipline)
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State of Utah
For Official Use Only
Department of Environmental Quality
Division of Air Quality
ATLAS Section
th
195 North 1950 West, 4
Floor
P.O. Box 144820
Salt Lake City, Utah 84114-4820
Postmark Date: __________________ Initials: _______
asbestos@utah.gov
Check #/Credit Card Amount: _____________________
ASBESTOS INDIVIDUAL CERTIFICATION APPLICATION FORM
Please read the instructions at the end of this form prior to completion. Please complete all sections of
the form or write N/A. Improperly completed forms may be rejected delaying your application.
A. Individual Certification Information
Name of Individual: ___________________________________________________________________________________________
Individual’s Home Address: _____________________________________________________________________________________
 Check this box to send certifica-
Street Address, Suite #, or P.O. Box
City
State
Zip Code
tion card to home address otherwise
company address will be used
Date of Birth: ______________ Height: ____________ Weight: ____________ Hair Color: ____________ Eye Color: ____________
month/day/year
feet/inches
pounds
Individual Telephone # (____) ____ - ______ ext. ______ Individual FAX # (____) ____ - ______ Email: ________________________
Employing Company Name: ____________________________________________________________________________________
Employing Company Mailing Address: ____________________________________________________________________________
Street Address, Suite No./P.O. Box
City
State
Zip Code
Company Telephone # (____) ____ - ______ ext. ______ Company FAX # (____) ____ - ______ Email: ________________________
B. Type of Individual Certification
 Initial Individual Certification (Please check this box, complete, and submit the entire form)
 Individual Recertification #ASB - _______________ (Please check this box, complete, and submit the entire form)
 Lost Individual Certification Card #ASB - _______________ (Please check this box, complete, and submit the entire form)
C. Asbestos Individual Certification Application Fee
Please read the instructions on the last page prior to completing this section
Total Asbestos
Asbestos Individual Certification Application
Individual Certification Application Fees
Individual Certification
Disciplines, Fees, and Surcharges
and Surcharges
Application Fees
 Lost Certification Card Replacement Fee ($33.00)
 Lost Card Certification Card Replacement Fee
($33.00)
 Non-Utah Accredited Training Provider Surcharge ($33.00)
 Asbestos Inspector Initial Renewal
Non-Utah Accredited Training Provider Surcharge
Trainer/Cert.#__________________________________
 Asbestos Management Planner Initial Renewal
________________________ X $33.00/certificate
Trainer/Cert.#__________________________________
$ __________________
(Total number of non-Utah Training Provider Course Certificates)
 Project Designer Initial Renewal
Trainer/Cert.#__________________________________
Individual Certification Application Fees
 Asbestos Supervisor Initial Renewal
Trainer/Cert.#__________________________________
______________ X $137.50/year
 Asbestos Worker Initial Renewal
(Total number of Asbestos Discipline(s))
Trainer/Cert.#__________________________________
(1 year certification maximum per discipline)
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D. Certification Statement
I hereby attest and affirm that the information included on this Asbestos Individual Certification Application Form, including any
attachments, is true and accurate to the best of my belief and knowledge. I acknowledge that any certification authorized pursuant to
this application will be subject to revocation if issuance was based on incorrect or inadequate information that materially affected the
decision to issue the Asbestos Individual Certification Application Form approval. I also attest and affirm that I will follow all work
practice standards required by Utah Administrative Code R307-801.
_________________________________________________________________________________________________________________________
Applicant’s Signature
Date Signed
_________________________________________________________________________________________________________________________
Applicant’s Printed Name
Applicant’s Title
Before delivering this Utah DEQ/DAQ Asbestos Individual Certification Application Form, please check to make
sure you have:
 Filled out all sections of the Asbestos Individual Certification
 Enclosed or paid by credit card the appropriate Asbestos
Application Form completely and attached additional information
Individual Certification Application Form fees?
as necessary?
 Signed and dated the Asbestos Individual Certification
 Made a copy of this Asbestos Individual Application Form for
Application Form?
your files?
Submit the completed Asbestos Individual Certification Application Form, supporting materials, and fees to:
Utah Department of Environmental Quality
Division of Air Quality
th
195 North 1950 West, 4
Floor
P.O. Box 144820
Salt Lake City, UT 84114-4820
or
asbestos@utah.gov
Official Use Only
PLEASE DO NOT WRITE IN THIS AREA
Official Use Only
Date Application Received _________________________ Date Additional Information Requested __________________
Month/Day/Year
Initials
Month/Day/Year
Initials
Date Amount/Fee Received ________________________ Date Additional Information Received ___________________
Month/Day/Year
$ Amount
Initials
Month/Day/Year
Initials
Date Application Reviewed _________________________ Date Notification Accepted/Rejected ____________________
Month/Day/Year
Initials
(circle one)
Month/Day/Year
Initials
Reason for Rejection _______________________________________________________________________________
_________________________________________________________________________________________________
Additional Information:
DAQA-529-18
Revision 1.1 - 6/27/18
2
General Instructions
This Asbestos Individual Certification Application Form must be properly completed and received by the Utah Department of
Environmental Quality/Division of Air Quality (UDEQ/DAQ), the appropriate fee must be paid, and you must have an Asbestos
Individual Certification Card from the UDEQ/DAQ prior to performing any regulated asbestos work activities. You can apply on-
line at http://asbestos-lead.utah.gov (please, no WWW) through the ALBoP (Asbestos/Lead-Based Paint) database, email back this
form to asbestos@utah.gov and pay with a credit card by calling 801-536-4000, or by sending this completed form and payment by the
US Postal Service. Please complete all forms by writing legibly (using blue or black ink) or completing this PDF fillable form. If you use
this form’s PDF fillable capability, please save it to your desktop before closing the document or all information will be lost.
Attach additional sheets of paper using the appropriate format, if necessary. Please redact the individual’s Social Security Number
if submitted to the UDEQ/DAQ.
C. Asbestos Individual Certification Application Fee
UDEQ/DAQ has established a fee of $137.50 per asbestos discipline/year for the certification of individuals who perform
regulated asbestos work activities. The UDEQ/DAQ has also established fees of $30.00/training course discipline for non-Utah
accredited training providers and $33.00 for lost individual certification card replacement. Regardless of the type of application
you are submitting, please properly complete and submit the form and the appropriate fee to the UDEQ/DAQ at the time of application.
Certification fees represent the cost for a complete certification year or any fraction thereof.
If this is a lost individual certification card application, check the appropriate boxes in the first column and second (Individual
Certification Application Fees and Surcharges) columns and put $33.00 in the third (Total Asbestos Individual Certification Application
Fees) column.
If you are applying for individual initial or renewal certification, check the appropriate asbestos individual certification discipline
box(es), check if this is an initial or renewal certification, and write the training course certificate number for all disciplines for which you
are requesting certification all in the first column. Next, put the total number of asbestos certification disciplines you are requesting and
multiply that number by $137.50, be sure to include the number of non-Utah accredited training provider asbestos discipline(s), multiply
that number by $33.00, and put the total of these two fees in the third column.
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