"Application for Wastewater Treatment Plant Operator Upgrade to Emergency Certification" - Massachusetts

Application for Wastewater Treatment Plant Operator Upgrade to Emergency Certification is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on April 11, 2016;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download "Application for Wastewater Treatment Plant Operator Upgrade to Emergency Certification" - Massachusetts

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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR
UPGRADE TO EMERGENCY CERTIFICATION
In accordance with 257 CMR 2.00, any person requesting emergency certification must apply in writing to the
Board of Certification. Through a majority vote and for a good cause shown, the Board will grant Emergency
Certification to enable an operator to work at a specified facility in a position for which the operator is not otherwise
certified. The Board may grant a Chief Operator an Emergency Certification only if the request is approved by the
appropriate regional DEP/BRP section chief. Emergency Certification shall not be granted to employees or
managers of contract operations and maintenance firms. Emergency certification shall be valid for no longer than
six months and cannot be renewed.
Instructions:
Type or print clearly in ink only.
Attach recent photo, with face, not less than one inch wide, or a copy of your driver's license. Please note
that this is a mandatory requirement.
The application must include a letter on its letterhead from the facility requesting the certification stating the
reason for the request.
Each application must be accompanied by a check/money order for $30.00 (non-refundable) payable to the
Commonwealth of Massachusetts.
Mail application, attachments, and check/money order to:
Department of Environmental Protection
P.O. Box 4062
Boston, MA 02211
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.
Application Date
Certification Number
Date of Birth
Driver’s License Number or State ID
Month / Day / Year
Applicant’s Name
First
MI
Last
ATTACH
PICTURE
Home Address
HERE
Street
Town
State
Zip
Phone Number
Email
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
ecupgr.doc · rev 4/11/2016
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR
UPGRADE TO EMERGENCY CERTIFICATION
In accordance with 257 CMR 2.00, any person requesting emergency certification must apply in writing to the
Board of Certification. Through a majority vote and for a good cause shown, the Board will grant Emergency
Certification to enable an operator to work at a specified facility in a position for which the operator is not otherwise
certified. The Board may grant a Chief Operator an Emergency Certification only if the request is approved by the
appropriate regional DEP/BRP section chief. Emergency Certification shall not be granted to employees or
managers of contract operations and maintenance firms. Emergency certification shall be valid for no longer than
six months and cannot be renewed.
Instructions:
Type or print clearly in ink only.
Attach recent photo, with face, not less than one inch wide, or a copy of your driver's license. Please note
that this is a mandatory requirement.
The application must include a letter on its letterhead from the facility requesting the certification stating the
reason for the request.
Each application must be accompanied by a check/money order for $30.00 (non-refundable) payable to the
Commonwealth of Massachusetts.
Mail application, attachments, and check/money order to:
Department of Environmental Protection
P.O. Box 4062
Boston, MA 02211
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.
Application Date
Certification Number
Date of Birth
Driver’s License Number or State ID
Month / Day / Year
Applicant’s Name
First
MI
Last
ATTACH
PICTURE
Home Address
HERE
Street
Town
State
Zip
Phone Number
Email
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
ecupgr.doc · rev 4/11/2016
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)
ecupgr.doc · rev 4/11/2016
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