Form LW904C "Maintenance Service Provider Qualification Certificate Application" - New Mexico

What Is Form LW904C?

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 LW904C by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW904C "Maintenance Service Provider Qualification Certificate Application" - New Mexico

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Maintenance Service Provider Qualification
New Mexico Environment Department
Certificate Application
Environmental Health Bureau
Part A
Liquid Waste Program
Applicant Information
Name of Applicant (Last, First)
Name of Company
Mailing Address
Company Mailing Address
City, State
Zip
City, State,
Zip
Phone Number
Company Contact Name and Phone Number:
Email Address
Company Email Address
Which Certifications are Current and Active? (Attach all certifications with this application)
Manufacturer:
Manufacturer:
Certification by the Manufacturer
Certificate # and Exp date:
NM Operator Certification for Small Advanced Wastewater Systems (Or higher)
State:
Certificate # and Exp date:
Certification as Wastewater Operator from another state
Approval Date:
Other Certification based on Credentials Approved by the Department:
Name All Proprietary Advanced Treatment Systems that you are applying for Qualification under 904(C) of Liquid Waste
Regulations 20.7.3 NMAC (NOTE: You must submit a “PART B” for each and every ATS that you are requesting approval to service)
For each of the Advanced Treatment Systems listed above, you must fill out an “ATS QUALIFICATION
YES
NO
FORM” for each ATS. Qualification Forms are Attached?
Do you have the ability to sample all units using manufacturer’s sampling protocol?
YES
NO
Will you be able to respond to emergency situations within 48 hours of being notified?
YES
NO
Do you use a contract for service that contains, at least, minimum standards approved by NMED?
YES
NO
Do you have a quality assurance/quality control plan acceptable to the department?
YES
NO
Will you notify NMED within 5 working days for any failed system?
YES
NO
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 working as a maintenance service provider. I understand that should I be approved as a maintenance
service provider on specific advanced treatment units, that I must be on-site for all activities involving the maintenance of these
advanced treatment systems.
Printed Name:
Signature
Date
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
☐ Maintenance Service Provider Qualification Certificate $50
Total Fee Paid
Check number
Date Paid
Payment Received By
Please Complete this Application Form(Part A) along with Part B Forms for each ATS you want to work on to : Michael Broussard, EHB Liquid Waste Program,
2450 Camino Edward Ortiz, Santa Fe, NM 87505; Fax 505-827-1839 Michael.Broussard@state.nm.us or 505-476-9125
Please note that the certificate of registration belongs ONLY to the trained applicant as approved and registered. It does not belong to the company. The
company name is associated with our records for administrative purposes. Anapproved individual must be at the site of any maintenance activity.
☐ Approved
☐ Denied
Maintenance Service Provider
☐ Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW 904C A/B 200701
Maintenance Service Provider Qualification
New Mexico Environment Department
Certificate Application
Environmental Health Bureau
Part A
Liquid Waste Program
Applicant Information
Name of Applicant (Last, First)
Name of Company
Mailing Address
Company Mailing Address
City, State
Zip
City, State,
Zip
Phone Number
Company Contact Name and Phone Number:
Email Address
Company Email Address
Which Certifications are Current and Active? (Attach all certifications with this application)
Manufacturer:
Manufacturer:
Certification by the Manufacturer
Certificate # and Exp date:
NM Operator Certification for Small Advanced Wastewater Systems (Or higher)
State:
Certificate # and Exp date:
Certification as Wastewater Operator from another state
Approval Date:
Other Certification based on Credentials Approved by the Department:
Name All Proprietary Advanced Treatment Systems that you are applying for Qualification under 904(C) of Liquid Waste
Regulations 20.7.3 NMAC (NOTE: You must submit a “PART B” for each and every ATS that you are requesting approval to service)
For each of the Advanced Treatment Systems listed above, you must fill out an “ATS QUALIFICATION
YES
NO
FORM” for each ATS. Qualification Forms are Attached?
Do you have the ability to sample all units using manufacturer’s sampling protocol?
YES
NO
Will you be able to respond to emergency situations within 48 hours of being notified?
YES
NO
Do you use a contract for service that contains, at least, minimum standards approved by NMED?
YES
NO
Do you have a quality assurance/quality control plan acceptable to the department?
YES
NO
Will you notify NMED within 5 working days for any failed system?
YES
NO
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 working as a maintenance service provider. I understand that should I be approved as a maintenance
service provider on specific advanced treatment units, that I must be on-site for all activities involving the maintenance of these
advanced treatment systems.
Printed Name:
Signature
Date
NMED LIQUID WASTE QUALIFICATION CERTIFICATE FEE
☐ Maintenance Service Provider Qualification Certificate $50
Total Fee Paid
Check number
Date Paid
Payment Received By
Please Complete this Application Form(Part A) along with Part B Forms for each ATS you want to work on to : Michael Broussard, EHB Liquid Waste Program,
2450 Camino Edward Ortiz, Santa Fe, NM 87505; Fax 505-827-1839 Michael.Broussard@state.nm.us or 505-476-9125
Please note that the certificate of registration belongs ONLY to the trained applicant as approved and registered. It does not belong to the company. The
company name is associated with our records for administrative purposes. Anapproved individual must be at the site of any maintenance activity.
☐ Approved
☐ Denied
Maintenance Service Provider
☐ Incomplete
Applicant notification, date, via, provide comments:
Approved Date:
Certificate Number:
Qualification Expiration Date:
NMED Official Name Printed:
NMED Official Signature:
Date:
Form LW 904C A/B 200701
Maintenance Service Provider Qualification
New Mexico Environment Department
Certificate Application
Environmental Health Bureau
Liquid Waste Program
Part B
MSP Application-ATS Qualification Form (Part B)
You must submit a separate “Part B” for each type of advanced treatment system(ATS) that you are requesting t to service. Fill out
one form for each Manufacture and include all model numbers. The department will determine whether you meet the regulatory
requirements and will send you a letter informing you that you have been approved or denied for maintaining this system. For all
systems that you are approved to operate, service and maintain , your name will be listed on the NMED website.
Applicant Information
Name of Applicant (Last, First)
Name of Company
Mailing Address
Company Mailing Address
City, State
Zip
City, State,
Zip
Phone Number
Company Contact Name and Phone Number:
Email Address
Company Email Address
1. Name of Advanced Treatment Unit(s) you are requesting to inspect, operate and maintain (Include Name
of Manufacturer, Series Name and Model Numbers)
Date of the last training you attended for
Have you completed a training and certification
this ATS?
YES
NO
program from the manufacturer on this ATS?
a. If You Answered YES to the question above
Please submit all certifications as part of this application
If You Answered NO to the question above you are required to answer the below listed questions.
b.
3. You must provide a written statement that describes trainings that you have received
on similar types of ATSs and describe your experience at operating, maintaining and
YES
NO
servicing these units. Is this statement attached?
4. Do you have operation and maintenance manuals for this ATS that would be made
YES
NO
available for NMED verification?
5. Do you have regular access to replacement parts for this ATS?
YES
NO
6. If the operation and maintenance of this ATS requires specialized tools, do you
N/A
YES
NO
have access to these tools?
By signing below, I agree that the foregoing information is true and correct to the best of my knowledge.
Signature
Date
Printed Name:
Maintenance Service Provider ATS Qualification
☐ Accepted
☐ 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 904C A/B 200701
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