ࡱ> NPM#` Rbjbjmm 7\A02Z$Z$Z$8$l$\202f%h'h'h'h'G()*|!0#0#0#0#0#0#0$2h4pG0]U-C(G(U-U-G0h'h'0E/E/E/U-|8h'h'!0E/U-!0E/E/E/h'Z% PoYZ$-E//000E/4q.v4E/4E/P[+Z+@E/+4),,[+[+[+G0G0.^[+[+[+0U-U-U-U-222D 222222  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION APPLICATION FOR CERTIFICATION AS AN ASBESTOS PROFESSIONAL Complete all sections of the application either by hand printing in ink or typing. Be sure to sign the completed application and include the appropriate application fee. Attach additional sheets as necessary. SEPARATE APPLICATON FORMS MUST BE SUBMITTED FOR EACH JOB CATEGORY. 1. APPLICANT: Name:  FORMTEXT   Date of Birth:  FORMTEXT   First Middle Initial Last Home Address:  FORMTEXT    FORMTEXT    FORMTEXT        FORMTEXT       Street City State Zip Home Telephone:  FORMTEXT   Social Security #:  FORMTEXT   Employer:  FORMTEXT   Employer Complete Address:  FORMTEXT   Employer Telephone:  FORMTEXT   Previous Certificate Number (if applicable):  FORMTEXT   2. CERTIFICATION INFORMATION: A)  FORMCHECKBOX  New  FORMCHECKBOX  Renewal (check only one) FOR OFFICE USE ONLY EMBED MSDraw \* mergeformat Fee paid $_____ check #_____ EMBED MSDraw \* mergeformat Approved For which one of the following are you applying? (check only one per application). B)  FORMCHECKBOX  WORKER  FORMCHECKBOX  MANAGEMENT PLANNER  FORMCHECKBOX  SUPERVISOR  FORMCHECKBOX  DESIGN CONSULTANT  FORMCHECKBOX  AIR MONITOR  FORMCHECKBOX  AIR ANALYST  FORMCHECKBOX  INSPECTOR  FORMCHECKBOX  BULK ANALYST C) Are you presently permitted, licensed, certified or registered in the asbestos abatement field with another state?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES: State  FORMTEXT   Number:  FORMTEXT   3. ENFORCEMENT ACTIONS: Have there been any enforcement actions taken against you with respect to asbestos abatement or asbestos associated activity during the past year?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES, include the name of the agency taking the action, and copies of correspondence relating to the enforcement action. 4. TRAINING: Please submit documentation regarding successful completion of training courses related to your job category. New applicants must submit attested copies of original certificates as well as current refresher training certificates. A. Initial training course requirements: Worker: 32 hours Annual Update: 8 hours Supervisor: 40 hours Annual Update: 8 hours Air Monitor: 40 hours Annual Update: 4 hours Inspector: 24 hours Annual Update: 4 hours Management Planner: 16 hours Annual Update: 4 hours Design Consultant: 24 hours* Annual Update: 8 hours Air Analyst: 36 hours Annual Update: ** Bulk Analyst: 36 hours Annual Update: *** * Design Consultants applicants who administer training courses must submit documentation of successful completion of a Department approved "Train-the Trainer" course (24-hour minimum). B. Renewal training course requirements: Renewal applicants must submit copies of applicable annual update training certificates (as listed above). Initial course certificates are not required for renewal applicants. ** Renewal applicants for Air Analyst must provide documentation of participation in a Maine-licensed laboratory's annual analyst QA/QC training; and A statement from a licensed Asbestos Analytical laboratory affirming that the applicant is proficient in air analysis through participation in the laboratory's administration of the AIHA's PAT program, including results of the last four rounds of the applicant's testing, or proof that the applicant is listed in the AIHA Asbestos Analyst Registry. *** Renewal applicants for Bulk Analyst must provide documentation of participation in a Maine-licensed laboratory's annual analyst QA/QC training; and A statement from a licensed Asbestos Analytical Laboratory affirming that the applicant is proficient in bulk analysis through participation in the laboratory's administration of the NVLAP or AIHA bulk quality assurance program, including results of the last 4 rounds of the applicant's testing. 5. EXPERIENCE REQUIREMENT FOR DESIGN CONSULTANT: Applicants for Asbestos Design Consultant must submit documentation of at least a bachelor's degree in either architecture, engineering, industrial hygiene, occupational health, or environmental, biological or life sciences and a minimum of 12 months of field experience directly associated with asbestos abatement activity; or possession of any valid asbestos professional certificate, excluding Asbestos Abatement Worker, for three years. 6. ANNUAL FEE: The application must include a non-refundable cashiers, certified or company check in the amount indicated below, made payable to the Maine Environmental Protection Fund: Worker: $25 Management Planner: $50 Supervisor: $50 Design Consultant: $50 Air Monitor: $50 Air Analyst: $50 Inspector: $50 Bulk Analyst: $50 7. STANDARD OPERATING PROCEDURES COMPLIANCE AGREEMENT:  FORMTEXT       Read and initial each box. The undersigned agrees that prior to engaging in any asbestos abatement or asbestos associated activity he/she will sign a statement attesting knowledge of and compliance with Maine DEP Licensed company/employer standard operating procedures.  FORMTEXT       If the undersigned is not currently employed or changes employers during the effective period of certification, the undersigned agrees that prior to engaging in any asbestos abatement or asbestos associated activity he/she will sign a statement attesting knowledge of and compliance with the new Maine DEP Licensed company/employer standard operating procedures. 8. PHOTO: Include one (1) color photo, approximately 2" X 2" with each application submitted. 9. 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I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. SIGNED:  DATE: FORMTEXT   PRINTED:  RETURN TO: Lead & Asbestos Hazard Prevention Program Department of Environmental Protection (BRWM) 17 State House Station Augusta, Maine 04333-0017 (207) 287-2651     Asbestos Professional 10/19/2007 QQQQQQQQQQRkdL$$Ifl\w,"9 t0644 layt5e/ $Ifgd5e/ QQQQQQ$RRRiRRxsYYYY$ h8(0^`0a$gd_*gd_*}kdL$$Ifl0,"9_ t0644 layt5e/ $Ifgd5e/ RRRRRRRRRRRRRRRRRRRRgd_* h8(0^`0gd_*$ h8(0^`0a$gd_*RRRRRRRRRh5e/mHnHuh5e/hh"h"CJOJQJ^JaJ h_*h"CJOJQJ^JaJ50&P:p?/ =!"#$%h /Dd5 T  0Ab/A+ne\Hp}V_c.Dn.A+ne\Hp}V_cPNG  IHDR2ZsRGB@}0PLTE9O pHYsYYNV.4IDATxI#9Q\ԕH E UVdFG AڿߖC}_hE~6[{F,CSum9γ anҔgt 4(i11a|hB%MИ`ӌfOјv#h^lM>  4r_, =iKN!03s4;u ՌChhmM5#:N3[&& Ml8HO4jl# ui,J44Od,$iJF66ndh4,ΐQ ǕbRی s1M4Ni0'xQӻ!8iiTJ^٢)MFЙFUѷ rJ#,V,$DoK8!g6*'iz9繩K@iǓ@J41; k?0MRkF{,|^? d;hb G."J^i ䷧yvu(#4*Ѥ&T#b}XtXVhړ1kr#|iڲOGV]V)s+7Ѥ NytMՓ0=?k=JQ]iG=Y!$v13A=6>RRUM'_4T \?*5nԴibeh_9O~otzj-!V-jicwnOs+Ќ0޴e;9qݨnzFlps9 %6ϾWbsyhw#h|PʱM4;Uc-Հ|l|Ϡ&yfO9O֝;Jє3 _Fe#wEbaS H-cѨhybu3DZI߸]y(g#v:zc ׏~4e'gˤϲHѯhco&f4fAEewbaѭjߌ&Ai4zSGccf^Stp},3ςfܒh|Xh~nGq ߏf|")`}̈$NH7asv=:h0mxnb۽|8x&Y6 i瓖6m=]''4M}ezl)ͦ<h+j#i jD<44d4=0ȧ+B}O66h& ߐnt_g=Ǜ@3,hiO(n4cG<:64wSl&4Ïy~1KwL ?NtML{u%Ɇ"4>]D8U7?͔G$lԝHGJdZ&LA[uY6%s1/u5 MEl@ӕ `sY! 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