ࡱ> #` vbjbjmm 7=BBBB'''8(TZ(4_:f)++++{,m./9999999$;h->p9Q2w,{,229BB++:4442pB8++9429444z5+) D '34N5T/:0_:4>3v>5>5H 00h41T[1D 0 0 099%4^ 0 0 0_:2222**BBBBBB  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION RENEWAL APPLICATION FOR LICENSING AS AN ASBESTOS TRAINING PROVIDER 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 (if applicable): FORMTEXT  Training Director (must be a Design Consultant): FORMTEXT  Title FORMTEXT      Is the applicant licensed or certified an asbestos training provider in another state?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, where: FORMTEXT  License or Registration Number: FORMTEXT  2. APPROVAL OF COURSES: The undersigned understands that each training course, conducted in Maine, will be approved by the DEP separately. The applicant will submit an application for training course approval to the Department for any course addition not previously approved; new courses will need to be audited during first presentation.  FORMCHECKBOX ABATEMENT WORKER (32 hrs) FORMCHECKBOX ANNUAL REFRESHER (8 hrs.) FORMCHECKBOX ABATEMENT SUPERVISOR (40 hrs) FORMCHECKBOX ANNUAL REFRESHER (8 hrs) FORMCHECKBOX MANAGEMENT PLANNER (16 hrs) FORMCHECKBOX ANNUAL REFRESHER (4 hrs) FORMCHECKBOX AIR MONITOR (16 hrs) FORMCHECKBOX ANNUAL REFRESHER (4 hrs) FORMCHECKBOX AIR MONITOR (40 hrs) FORMCHECKBOX INSPECTOR (24 hrs) FORMCHECKBOX ANNUAL REFRESHER (4 hrs) FORMCHECKBOX DESIGN CONSULTANT (24 hrs) FORMCHECKBOX ANNUAL REFRESHER (8 hrs) FORMCHECKBOX AIR ANALYST (36 hrs) FORMCHECKBOX BULK ANALYST (36 hrs.) 3. RENEWAL REQUIREMENTS: A renewal applicant for Training Provider must submit documentation including the following: 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 any changes of your original application. B.  FORMCHECKBOX  Included with this renewal application is a list of current employees including expiration of state certification and training accreditation.  FORMCHECKBOX  Any changes and/or addition(s) to course information and materials. 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, include the name of the agency taking the action 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 $500 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 ALSO UNDERSTAND THAT THE ISSUANCE OF A FRAUDELENT STUDENT CERTIFICATE, OR THE VIOLATION OF ANY PROVISION OF D.E.P. 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