Form LW904B2F "Third Party Evaluator Application Form" - New Mexico

What Is Form LW904B2F?

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 July 1, 2020;
  • 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 LW904B2F by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW904B2F "Third Party Evaluator Application Form" - New Mexico

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New Mexico Environment Department
Third Party Evaluator Application Form
Environmental Health Bureau
LW 904B2f
Liquid Waste Program
You must submit this completed application along with all required documentation listed on the bottom of this page for your application to be deemed “complete.”
NOTE: This application is required for any third party evaluators who does not meet the qualification requirements under Section
904(B)(2)(a) through (e), and who are seeking qualification under Section 904(B)(2)(f) of the New Mexico Liquid Waste Disposal
and Treatment Regulations 20.7.3 NMAC.
If you are a CID licensed contractor with an MM-1, MM-98, MS-1 or MS-3 license you do not need to submit an application. If you
are PE, RS, REHS, accredited by NSF or a NEHA installer you do not need to fill out this application.
Name of Applicant
Email Address
Name of Company
Phone Number
Mailing Address
City, State, Zip
Professional Experience
1.
Do you have at least 3 years of professional experience inspecting and evaluating onsite liquid waste systems in
YES
NO
New Mexico? (Must provide evidence of experience, signed and dated evaluations)
2.
Are you currently certified by the National Association of Wastewater Technicians (NAWT) as an onsite system
YES
NO
(spetic, liquid waste) Inspector?
NAWT Expiration Date:
3.
What date does your Current NAWT Inspector certification expire?
Years of experience:
4.
How long have you been certified by the National Association of Wastewater Technicians (NAWT) as an
inspector?
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 to working as a Third Party Evaluator. By signing below, I agree that the foregoing information is true and correct.
I understand that I cannot make repairs to any system or its components, install risers, baffles, tees, lids, clean-outs, or do any other work
which is beyond the scope of work which requires a CID license. I understand that if I should perform any of this work without the appropriate
CID license, this Third Party Evaluator certification will be revoked by NMED and a letter will be sent to NAWT seeking their revocation as
well.
I understand that I cannot perform evaluations on advanced treatment systems or unpermitted systems. I also understand that it is my
responsibility to submit my NAWT renewal certifications to NMED prior to the expiration of my certification.
Third Party Evaluator Name Printed
Third Party Evaluator Signature
Date
☐ Third Party Evaluator Qualification Certificate $50
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
Total Fee Paid
Check number:
Date Paid
Payment Received By
Third Party Evaluator Application Submittal Requirements
Applications missing the below listed items will be denied and returned without action.
Circle Yes or No as applicable
Third Party Evaluator Application Form- Completed and signed
YES
NO
Copy of NAWT Inspector Certification – must be current and valid
YES
NO
Professional Experience – attach a letter which describes your professional experience; this should include how many years you
YES
NO
have been inspecting and evaluating on-site liquid waste systems in New Mexico.
Attach copies of 3 Property Transfer Evaluations/Inspections that you have completed. Submit one evaluation form for each of
YES
NO
the three years that you have been conducting these evaluations/inspections in 2013 and prior years. These evaluation / inspection
forms must have your signature on them as the evaluator/inspector.
Please send your complete application to:
Michael Broussard, EHB Liquid Waste Program, 2540 Camino Edward Ortiz, Santa Fe, NM 87507; Fax 505-827-1839
For more information please contact Michael Broussard at
michael.broussard@state.nm.us
or 505-476-9125
Third Party Evaluator Qualification Application
Approved
Denied
Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW 904B2f 200701
New Mexico Environment Department
Third Party Evaluator Application Form
Environmental Health Bureau
LW 904B2f
Liquid Waste Program
You must submit this completed application along with all required documentation listed on the bottom of this page for your application to be deemed “complete.”
NOTE: This application is required for any third party evaluators who does not meet the qualification requirements under Section
904(B)(2)(a) through (e), and who are seeking qualification under Section 904(B)(2)(f) of the New Mexico Liquid Waste Disposal
and Treatment Regulations 20.7.3 NMAC.
If you are a CID licensed contractor with an MM-1, MM-98, MS-1 or MS-3 license you do not need to submit an application. If you
are PE, RS, REHS, accredited by NSF or a NEHA installer you do not need to fill out this application.
Name of Applicant
Email Address
Name of Company
Phone Number
Mailing Address
City, State, Zip
Professional Experience
1.
Do you have at least 3 years of professional experience inspecting and evaluating onsite liquid waste systems in
YES
NO
New Mexico? (Must provide evidence of experience, signed and dated evaluations)
2.
Are you currently certified by the National Association of Wastewater Technicians (NAWT) as an onsite system
YES
NO
(spetic, liquid waste) Inspector?
NAWT Expiration Date:
3.
What date does your Current NAWT Inspector certification expire?
Years of experience:
4.
How long have you been certified by the National Association of Wastewater Technicians (NAWT) as an
inspector?
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 to working as a Third Party Evaluator. By signing below, I agree that the foregoing information is true and correct.
I understand that I cannot make repairs to any system or its components, install risers, baffles, tees, lids, clean-outs, or do any other work
which is beyond the scope of work which requires a CID license. I understand that if I should perform any of this work without the appropriate
CID license, this Third Party Evaluator certification will be revoked by NMED and a letter will be sent to NAWT seeking their revocation as
well.
I understand that I cannot perform evaluations on advanced treatment systems or unpermitted systems. I also understand that it is my
responsibility to submit my NAWT renewal certifications to NMED prior to the expiration of my certification.
Third Party Evaluator Name Printed
Third Party Evaluator Signature
Date
☐ Third Party Evaluator Qualification Certificate $50
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
Total Fee Paid
Check number:
Date Paid
Payment Received By
Third Party Evaluator Application Submittal Requirements
Applications missing the below listed items will be denied and returned without action.
Circle Yes or No as applicable
Third Party Evaluator Application Form- Completed and signed
YES
NO
Copy of NAWT Inspector Certification – must be current and valid
YES
NO
Professional Experience – attach a letter which describes your professional experience; this should include how many years you
YES
NO
have been inspecting and evaluating on-site liquid waste systems in New Mexico.
Attach copies of 3 Property Transfer Evaluations/Inspections that you have completed. Submit one evaluation form for each of
YES
NO
the three years that you have been conducting these evaluations/inspections in 2013 and prior years. These evaluation / inspection
forms must have your signature on them as the evaluator/inspector.
Please send your complete application to:
Michael Broussard, EHB Liquid Waste Program, 2540 Camino Edward Ortiz, Santa Fe, NM 87507; Fax 505-827-1839
For more information please contact Michael Broussard at
michael.broussard@state.nm.us
or 505-476-9125
Third Party Evaluator Qualification Application
Approved
Denied
Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW 904B2f 200701