Form LW904E5 "Installer Specialist Renewal Application Form" - New Mexico

What Is Form LW904E5?

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 LW904E5 by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW904E5 "Installer Specialist Renewal Application Form" - New Mexico

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Installer Specialist Renewal Application Form
New Mexico Environment Department
Environmental Health Bureau
LW 904E5
Liquid Waste Program
Installer Specialist
RENEWAL
Application Form
You must submit this completed application form along with all required documentation listed on the bottom of this page for your application to be deemed “complete”
Name of Applicant
Email Address
Name of Company
Phone Number
Mailing Address
City, State, Zip
CID Licensure
Which CID License(s) do you currently hold? (circle applicable)
License Expiration Date:
MM-1
MM-98
MS-1
MS-3
Approved Continuing Education Units
Have you completed 16 hours of training credits approved by NMED for this Installer Specialist category
YES
NO
within the past 3 years? (
Note: Training CEUs must be approved by NMED to meet KSAs for this category of certification)
Compliance and Criminal Convictions
Have you been issued any Compliance Orders within the past 3 years for violation of any provision of
1.
YES
NO
the Liquid Waste Regulations 20.7.3 NMAC?
Have you had any criminal convictions pursuant to NMSA 1978, Section 74-1-10 within the past five
2.
YES
NO
years for violation of any provision of the Liquid Waste Regulations 20.7.3 NMAC?
By signing below, I ackcnowledge that I have read the Liquid Waste Disposal and Treatment Regulations and I understand the
sections of the regulations that pertain to performing as an Installer Specialist. By signing below, I agree that the foregoing
information is true and correct.
Installer Specialist Name Printed
Installer Specialist Signature
Date
☐ Installer Specialist Renewal Qualification Certificate $75
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
Total Fee Paid
Check number:
Date Paid
Payment Received By
Installer Specialist Renewal Application Submittal Requirements
Applications missing the below listed items will be denied and returned without action. Circle Yes or No as applicable
YES
NO
Installer Specialist Renewal Application Form- Completed and signed
Copy of CID License – must be current and valid
YES
NO
Copy of CEU Certificates showing 16 hours of CEUs completed within the past 3 years of this application date.
Applicant must demonstrate that the CEUs have been approved
All CEUs must pertain to the installation of onsite systems.
YES
NO
for Installer Specialist by the department or include documentation that allows NMED to make determination as
whether these CEUs meet KSAs for this category of certification. Course outlines to include instructor qualifications
may be submitted for review and approval prior to completing courses or attending conferences.
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
Installer Specialist Renewal
Approved
Denied
Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
LW 904E5 200701
Installer Specialist Renewal Application Form
New Mexico Environment Department
Environmental Health Bureau
LW 904E5
Liquid Waste Program
Installer Specialist
RENEWAL
Application Form
You must submit this completed application form along with all required documentation listed on the bottom of this page for your application to be deemed “complete”
Name of Applicant
Email Address
Name of Company
Phone Number
Mailing Address
City, State, Zip
CID Licensure
Which CID License(s) do you currently hold? (circle applicable)
License Expiration Date:
MM-1
MM-98
MS-1
MS-3
Approved Continuing Education Units
Have you completed 16 hours of training credits approved by NMED for this Installer Specialist category
YES
NO
within the past 3 years? (
Note: Training CEUs must be approved by NMED to meet KSAs for this category of certification)
Compliance and Criminal Convictions
Have you been issued any Compliance Orders within the past 3 years for violation of any provision of
1.
YES
NO
the Liquid Waste Regulations 20.7.3 NMAC?
Have you had any criminal convictions pursuant to NMSA 1978, Section 74-1-10 within the past five
2.
YES
NO
years for violation of any provision of the Liquid Waste Regulations 20.7.3 NMAC?
By signing below, I ackcnowledge that I have read the Liquid Waste Disposal and Treatment Regulations and I understand the
sections of the regulations that pertain to performing as an Installer Specialist. By signing below, I agree that the foregoing
information is true and correct.
Installer Specialist Name Printed
Installer Specialist Signature
Date
☐ Installer Specialist Renewal Qualification Certificate $75
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
Total Fee Paid
Check number:
Date Paid
Payment Received By
Installer Specialist Renewal Application Submittal Requirements
Applications missing the below listed items will be denied and returned without action. Circle Yes or No as applicable
YES
NO
Installer Specialist Renewal Application Form- Completed and signed
Copy of CID License – must be current and valid
YES
NO
Copy of CEU Certificates showing 16 hours of CEUs completed within the past 3 years of this application date.
Applicant must demonstrate that the CEUs have been approved
All CEUs must pertain to the installation of onsite systems.
YES
NO
for Installer Specialist by the department or include documentation that allows NMED to make determination as
whether these CEUs meet KSAs for this category of certification. Course outlines to include instructor qualifications
may be submitted for review and approval prior to completing courses or attending conferences.
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
Installer Specialist Renewal
Approved
Denied
Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
LW 904E5 200701