ࡱ> #` dbjbjmm 1hP6BBBB)))84*Dx*b8fx+~,,,,-V+//d7777777$9h0<p792--227BB,,8M4M4M42dB8,,7M427M4M4zM4,l+ _)2|M44,280b8M4<y3v<M4<M4DS0v0TM41Da18S0S0S0773^S0S0S0b82222"d"4"BBBBBB  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION RENEWAL APPLICATION FOR LICENSING AS AN ASBESTOS CONSULTANT Complete all sections of the application either by hand printing in ink or typing in the gray areas. Print out and sign the completed application and mail to Maine DEP with the appropriate application fee. Attach additional sheets as necessary. 1. Applicant:Company Name FORMTEXT  Company Address FORMTEXT  City FORMTEXT  State FORMTEXT  Zip FORMTEXT      Company Phone Number FORMTEXT  e-mail address FORMTEXT  Previous License Number: FORMTEXT  Responsible Person: FORMTEXT  Title FORMTEXT  Is the applicant licensed or certified an asbestos consultant in another state?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, where: FORMTEXT  License or Registration Number: FORMTEXT  2. Consultant Categories: check either A or BA)FULL FORMCHECKBOX Conducting: (Can only perform activities checked and as submitted in SOPs) FORMCHECKBOX Monitoring FORMCHECKBOX Design FORMCHECKBOX InspectionB) FORMCHECKBOX IN HOUSE IDENTIFICATION & MANAGEMENT UNIT, to conduct asbestos associated activities on owner properties only 3. RENEWAL REQUIREMENTS: A renewal application for an Asbestos Consultant license must meet the application requirements set forth below and submit attesting documentation: A.  FORMCHECKBOX  By signing this renewal application, the applicant hereby confirms that the information; submitted in our original application, is currently in effect and unchanged. or  FORMCHECKBOX  Included with this renewal application are any changes to the information in our original application, including standard operating procedures. B.  FORMCHECKBOX  Included with this renewal application is a list of current employees including expiration dates of state certification and training certificates. 4. ENFORCEMENT ACTIONS: Have there been any enforcement actions taken against the company with respect to asbestos abatement activities during the past year? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If YES, provide detailed information on the enforcement action(s) and copies of all correspondence relating to the enforcement action. (Note: Notices of violation are considered enforcement actions.) 5. FEE: The application must include a non-refundable cashiers, certified or company check in the amount of $250 dollars made payable to the Maine Environmental Protection Fund. 6. SIGNATURE: I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED THE INFORMATION SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS THERETO AND THAT, BASED ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION, I BELIEVE THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. I AM ALSO AWARE THAT ALL ASPECTS OF ASBESTOS ABATEMENT ACTIVITIES ARE SUBJECT TO INSPECTION AT ANY TIME BY THE MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION. 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