"Application for Wastewater Treatment Plant Operator Status Change Form" - Massachusetts

Application for Wastewater Treatment Plant Operator Status Change Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on June 10, 2016;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR
STATUS CHANGE FORM
In accordance with 257 CMR 2.00, to request a change in status as a certified wastewater treatment plant operator,
you must apply in writing to the Board of Certification. By majority vote, the Board may issue a change in status to
any operator who meets all the requirements. The Board will notify the applicant its decision in writing.
Type or print clearly in ink only.
ATTACH A COPY OF A RECENT GOVERNMENT ISSUED PHOTO ID (i.e., driver’s license, passport,
etc.). PLEASE NOTE THIS IS A MANDATORY REQUIREMENT.
Mail to: Board of Certification of Wastewater Treatment Plant Operators
NEIWPCC
650 Suffolk St., Suite 410
Lowell, MA 01854
Current Information
Application Date
Certification Number
Date of Birth
Driver’s License Number or State ID
Month / Day / Year
Applicant’s Name
First
MI
Last
ATTACH
Home Address
PICTURE
Street
Town
State
Zip
HERE
Phone Number
Email
Change Information or Status
Check Type of Status Change:
Active to inactive – must show no wastewater activities in that calendar year.
Inactive to active – must submit 10 TCHs in the same calendar year that you choose to become active.
“When and if” to “Operator in Training” – Must show employment at a graded wastewater treatment facility.
“Operator in Training” to “Full” – Must show specific job responsibilities and experience in the wastewater
field for their license and grade.
New address (provide new address):
Please complete all applicable sections on the front and back of this Application and attach all
required materials. The Board will not consider incomplete Applications.
I, ___________________________________(print) do solemnly swear (affirm) that all the information presented in
this application is true in substance and effect.
Signature_____________________________(sign)
Date_________________
For Official Use Only
Date Received
Board Date
Approval of
Status and Comments
Certification Number
Board Yes/No
Statchng.doc · rev. 6/10/2016
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR
STATUS CHANGE FORM
In accordance with 257 CMR 2.00, to request a change in status as a certified wastewater treatment plant operator,
you must apply in writing to the Board of Certification. By majority vote, the Board may issue a change in status to
any operator who meets all the requirements. The Board will notify the applicant its decision in writing.
Type or print clearly in ink only.
ATTACH A COPY OF A RECENT GOVERNMENT ISSUED PHOTO ID (i.e., driver’s license, passport,
etc.). PLEASE NOTE THIS IS A MANDATORY REQUIREMENT.
Mail to: Board of Certification of Wastewater Treatment Plant Operators
NEIWPCC
650 Suffolk St., Suite 410
Lowell, MA 01854
Current Information
Application Date
Certification Number
Date of Birth
Driver’s License Number or State ID
Month / Day / Year
Applicant’s Name
First
MI
Last
ATTACH
Home Address
PICTURE
Street
Town
State
Zip
HERE
Phone Number
Email
Change Information or Status
Check Type of Status Change:
Active to inactive – must show no wastewater activities in that calendar year.
Inactive to active – must submit 10 TCHs in the same calendar year that you choose to become active.
“When and if” to “Operator in Training” – Must show employment at a graded wastewater treatment facility.
“Operator in Training” to “Full” – Must show specific job responsibilities and experience in the wastewater
field for their license and grade.
New address (provide new address):
Please complete all applicable sections on the front and back of this Application and attach all
required materials. The Board will not consider incomplete Applications.
I, ___________________________________(print) do solemnly swear (affirm) that all the information presented in
this application is true in substance and effect.
Signature_____________________________(sign)
Date_________________
For Official Use Only
Date Received
Board Date
Approval of
Status and Comments
Certification Number
Board Yes/No
Statchng.doc · rev. 6/10/2016
STATEMENT OF QUALIFICATIONS
This form is to be completed by each applicant. This information is needed to determine your status as a certified operator. All related wastewater
field experience must be submitted on this form and any additional information may also be submitted separately, but in similar form.
STATE, COUNTRY, OR PROVINCE WHERE CERTIFIED
CERTIFICATION DATE
CERTIFICATION #
GRADE/LEVEL
STATUS
EDUCATION
INSTITUTION and ADDRESS
YEARS ATTENDED
DEGREE GRANTED
STUDIES
HIGH SCHOOL:
COLLEGE:
UNIVERSITY:
OTHER:
COURSE TITLES
INSTITUTION and ADDRESS
Month/Day/Year - Month/Day/Year
TOTAL HOURS
1.
2.
3.
4.
List only those jobs which have been in the wastewater treatment field. Describe specific duties (responsibilities) performed in the job title
indicated. Please use the same format on a separate sheet if you need more space.
CURRENT EMPLOYER NAME and ADDRESS, FACILITY GRADE, JOB TITLE, EMPLOYMENT DATES Month(s)/Year(s)
OPERATIONS: (Records, reports, equipment operating, sludge handling, process control functions, etc.)
MAINTENANCE: (Pumps, level controls, chlorination, etc.)
LABORATORY PROCEDURE: (Process control and regulatory testing)
COLLECTION OR DISTRIBUTION: (Operation and maintenance procedures)
PREVIOUS EMPLOYER NAME and ADDRESS, FACILITY GRADE, JOB TITLE, EMPLOYMENT DATES Month(s)/Year(s)
OPERATIONS: (Records, reports, equipment operating, sludge handling, process control functions, etc.)
MAINTENANCE: (Pumps, level controls, chlorination, etc.)
LABORATORY PROCEDURE: (Process control and regulatory testing)
COLLECTION OR DISTRIBUTION: (Operation and maintenance procedures)
Statchng.doc · rev. 6/10/2016
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