ࡱ> #` \bjbjmm 7d ,BBBBT(((8(4)T6f)****+,l,8a5c5c5c5c5c5c5$7h9p5Q/++//5BB**5111/pB8**a51/a511:52,zu2*) `$(%0a2 2506k2 \:0v\:u2\:u2P#--h1.Tq.D#-#-#-55#1^#-#-#-6////TTT!TTT!4"BBBBBB  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION NEW 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 certifies that they understand on behalf of the training provider that each training course needs to be approved by the DEP separately and distinctly from this licensure application. 3. APPLICATION REQUIREMENTS: An applicant for Training Provider must submit documentation including the following: The name and qualifications of the Training Director; B. A list of the qualifications and resumes of the applicant's instructors who will be teaching the Department approved training courses; C. A detailed description of the number and quality of supplies and equipment necessary to perform the instructional services it proposes to provide; D. A sample original student certificate issued upon successful completion of course(s); wallet cards may be used in conjunction with an original certificate; E. A statement that paperwork, including names, social security numbers, and exam scores, involving course participants, will be forwarded to the Department within 5 days of course completion; F. A description of the method that the Training Provider will use to notify course dates to the Department. A course must be notified 10 calendar days before the course using a Department approved course notification form; G. A statement that the Training Provider will issue student certificates within two weeks of the successful completion of the initial or refresher course; A statement that the Training Provider maintains student records for a period of seven years and will make them available to the Department within 24 hours of request; or A statement that any Training Provider, whose principal place of business is outside the State of Maine, who provides Department-approved training to individuals seeking a state certificate, will make information required by this application available to the Department within 5 business days of receipt of a request for information from the Department, if applicable. I. A list of all asbestos associated citations and notices of violation received in the United States during the last two years including the name of the issuing agency or department, the final disposition of such citation or notice, and, if the applicant's principal owner or operator or officer has received an asbestos associated citation or notice while owning or operating another company in the previous two years, a list of those violations; 4. FEE: The application must include a non-refundable cashiers, certified or company check in the amount of $500 dollars made payable to the Maine Environmental Protection Fund. 5. SIGNATURE: I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED THE INFORMATION SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS THERETO AND THAT, BASED ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION, I BELIEVE THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. I ALSO UNDERSTAND THAT THE ISSUANCE OF A FRAUDELENT STUDENT CERTIFICATE, OR THE VIOLATION OF ANY PROVISION OF D.E.P. CHAPTER 425 OR OTHER APPLICABLE LAWS AND REGULATIONS INCLUDING THE MODEL ACCREDIATION PLAN (MAP), CONSTITUTES THE GROUNDS FOR THE SUSPENSION OR REVOCATION OF THE TRAINING PROVIDER'S LICENSE, THE DENIAL OF THE RENEWAL OF THE LICENSE, AND/OR OTHER ENFORCEMENT ACTION DEEMED APPROPRIATE BY THE DEPARTMENT. SIGNED:  DATE: FORMTEXT 0=>MN[\ijt ŷųrbrTrBr#h'ho5CJOJQJ^JaJh'ho6OJQJ^Jh'ho5CJOJQJ^Jh'hoOJQJ^Jh'ho5CJ$OJQJ^JhKf@B*CJphhKf@B*CJphhKf@B*CJphhKfhKfB*CJOJQJphhKfB*CJ OJQJphhKfB*CJOJQJphhKfOJQJmHnHu"jhKfOJQJUmHnHu0=>Mt~~~~$ h8(a$gdo$da &#$+Daa$$dh$q} &#$+D.H/Ha$$dh<q`&#$+De.H/Ha$$dh<q`&#$+De.H/H^a$ &/ \\\ yikd/$$Ifl$$ t044 laytKf $IfgdKfgdo h8(gdo  $IfgdKf $IfgdKfikd/$$Ifl$$ t044 laytKf   > @ T V X ^ ` n p k'j4h'hoOJQJU^J'j>4h'hoOJQJU^J'j^3h'hoOJQJU^J'j1h'hoOJQJU^J#h'hoOJQJ^JmHnHu'jH0h'hoOJQJU^Jh'hoOJQJ^J!jh'hoOJQJU^J    z $IfgdKf|kd"1$$Ifl0$( t044 laytKf  > $IfgdKf $IfgdKfikd1$$Ifl$$ t044 laytKf z $IfgdKf|kd2$$Ifl0$6  t044 laytKf b n $IfgdKf $IfgdKfikd3$$Ifl$$ t044 laytKf     + , < = G H I g h 0 1 8 9 C ˷إˑإ}إiإ'j:h'hoOJQJU^J'jp8h'hoOJQJU^J'j6h'hoOJQJU^J#h'hoOJQJ^JmHnHu'j:6h'hoOJQJU^Jh'hoOJQJ^J!jh'hoOJQJU^J,jh'hoOJQJU^JmHnHu! 7. $IfgdKfkdB5$$Iflֈ*46c $W-- t044 laytKf  - < i $IfgdKfikd5$$Ifl$$ t044 laytKfi j k ]T $IfgdKfkd7$$Ifl\ l$ b$ t044 laytKfk l $IfgdKfikd$8$$Ifl$$ t044 laytKf zqzq $IfgdKf $IfgdKf|kd,9$$Ifl0$ t044 laytKf 2 8 ]TKTK $IfgdKf $IfgdKfkd9$$Ifl\~ $ &  t044 laytKfC D   <>RTVEFJںںںںںں~lںںXlں'jz?h'hoOJQJU^J#h'hoOJQJ^JmHnHu'j=h'hoOJQJU^J'j<h'hoOJQJU^J'j&<h'hoOJQJU^Jh'hoOJQJ^J$jh'hoU^JmHnHu!jh'hoOJQJU^J'j:h'hoOJQJU^J]T $IfgdKfkdL;$$Ifl\~ $ &  t044 laytKf $IfgdKfikd;$$Ifl$$ t044 laytKfJA $IfgdKfkd=$$Iflr!$~v t044 laytKf< $IfgdKfikd=$$Ifl$$ t044 laytKfz $IfgdKf|kd>$$Ifl0$t t044 laytKfG $IfgdKfikd.?$$Ifl$$ t044 laytKfGHIz $IfgdKf|kdV@$$Ifl0 $" t044 laytKfIJ)*$ikdA$$Ifl$$ t044 laytKf $IfgdKfikd@$$Ifl$$ t044 laytKfJb'(*+I2>Svxyzxyóxm^jh'hoOJQJUh'hC$OJQJhXGhC$OJQJhC$OJQJhoOJQJh'ho5OJQJho5OJQJh'hoOJQJh'ho5CJOJQJ^Jh'hoOJQJ^Jh'ho5OJQJ\^Jh'hoOJQJ\^J"h'ho5CJOJQJ\^J!*+bc^_AB h8(gdo & F h8(gdo h8(0^`0gdo h8(h^h`gdo .gdoxz h8(`^``gdo h8(h^h`gdo h0^`0gdC$ h8(0^`0gdo$ h8(a$gdo & F h8(gdo \ $IfgdKf h8(0^`0gdo .gdo h8(h^h`gdo \\\ \\\\\\\\\\\\\\\\\\hKfhC$hohjhUh'hoCJOJQJh'ho5OJQJh'hoOJQJh'hoOJQJmHnHuUjh'hoOJQJU#jPAh'hoOJQJU  PRINTED:  RETURN TO: Lead & Asbestos Hazard Prevention Program Department of Environmental Protection (BRWM) 17 State House Station Augusta, Maine 04333-0017 (207) 287-2651     Training Provider 10/19/2007 \\\\\\[RRRR $IfgdKfkdA$$Ifl\w,"9 t0644 laytKf\\ \!\"\X\\\\|bbbbbb$ h8(0^`0a$gdogdo}kdsB$$Ifl0,"9_ t0644 laytKf\\\\\\\\\\\\\\\\\\\ h8(0^`0gdo$ h8(0^`0a$gdo50&P:po/ =!"#$%h /Dd5 T  0Ab/A+ne\Hp}V_c.D/n.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$lԝHGJdZ&LA[uY6%s1/u5 MEl@ӕ `sY! QsKUC֋MP7ipЃN#@;4QfkG4(HP'CgqkvB^\5lXi)7h6c)بn/cR^ iK4Jo?6pа Z`%Sxph$R}k '8V}a=\33eLP4+-Y* \a<)^Qf)M%m'rJ`_-{jf4ZAC[krg(w38N<5V&i73b`2_>Whʉ!Lsws0fiI+4Wwi6DWNEy+(zUy'vylK\[joȬwY+#)}DIOS)Xwh^SX[4⢋$El {|cw>8~ $Gvg(ӎkt[H嶀NOV#MF3nEBUEiu;74k him];_qi:82JCC[5ei;+XZ$78- /=vo[h 8@ }7u:qK=-шi$V դNPo};Hp:! -$ۦ($Mci ޅ37rvKdOJ/}; = Fu4)!44g9f 7 ű'RF.@dV c$u*4|F[V Dp/ +Ҵ% h$( D'<1{M1]^S MBy4=ն]"H.~|mDq ToY 'k4P>) Nh%f@IM'B kd3h|[t+[B3«7'=P1:0>8 !/. p{u^c@#h'3f |t{PEӒƢg msJӿv! sb̢%L  Edb~ kb4ftAqQ j Yf9 +4i"xQٖ%H355S~Q!׿j{SNki0vsK-nM,5[.=h hXOР ͦkN="Oa]dO#ɮL炦DZcJa{@Stn4Ke͝&ךJ(n.6F Pj[?yćE4e(i/.pr<̶pG4H7ӷiDKuc5d8[5YB9Mٴ;t7hx7?M +iFOE Q5}bE\Ti;l!u@(JFvѻ[vE9DiS#&I _Ny|hr9k4v kq>O^9RNdçk֛AkpPѸx fiF漵l9 Z(w<}3ѬEdnϝ9L48/Q`b`'섳$][KO~y)4:4v0uwLіƎjR'R74a`-9cdoj`v174nh,Ur·Lvgz3o2YEki؍+WWYrD9 rD&_Dütd:q{lQ/x|MAz,tycNBFq7hwlK>*|m}iX-okbsh/3x|8@M5m;8J`w:qs߱w-+RF\[6B[4k b hjj;˕pgwY+NS雺URƖV"B"4 1ՋhUK ݥsZP`fcjC͢6꨸;^P7X]>3~g̖YHqyp+!ӏ3'8n %l:zq}E5EKm ;.MB7yFQfè 1pneRihGCa:Vک'4µӖ2 MS^l4݆<-wai&&"p#3,rUGiZмbN ; yy0PI7hSkuA@wRbˀKOhp qy5ŌzmqgM:V ֑.hvLQg)l텞^'CZ@AP7ka\4])É&'woИvDRޘ$a)քh4B;pejͪ{=Zy'ٳ k:VΛUyYҨLVǮpKi௙7qΏ灕iwt64^ BB}dd*Y/lufY]#ҰJ5)ٍѠpQ8 ufz i^Jek4IEb,hu ѱi&/Fgd:J(\dS3'#jP3vl۳cN3 K>XdL+'݌&FhD+/,m84ۗwą-2&xFo#Ƚ8#Ue#Zu2G#f$uiz-YNFL xF3&pkWhhD!@9ͤ ␾DKM֫/JG' /-u.1Ac6ULA{W f@#.\`l1BEDu4[izYдJSۼp15 0RTtLcUɋ0ceryidjhv22eHry&ݎ;4^q .M WU5 e ap$̧r.hsյ~8mo4S\ƯJqw4QNqGlhؠͶ,DI}T}-'rw? ٴ)_EԓzZIa.?"‡YYa-z1[`hu49gkBthi/O48_ak54\h΃{ZL`4aVo]X_l+څ<;Vj`4^a ޡ_/7411Ҹjf|@i޷qXԹò%,YJw|F71 ݵ4B9h;s4R~bZZ#] Q D`CYj4, 5IQכkwi\˺YEv2,\F2o#j'hV3ƲTx fBYY%45]e+C'SgR-U=bNu.85hn҄K0!tLP,KoEa&L3|nL3kK8q㣻ŢAH&"|uL$cZ%^#YGeG?*%;y0B3-il|3GV[{J/nc˥UYx33Ar mn.4D"kW^Y&hSBa.EhZnd)xct?@f<ߣhU3>Uԑt^¶QlNuL4nj'(G4 Ty}nAJC@F哎&yΚjv0o+lZjM&; Mw~ᗖVɻ7Q|(kЉ#dwZ`Vbٛxݽ\;\xFs(fL5Zl0uIw D%7@#glt밴~&^ .tiQqi(b?ޣɅ_1е2JG;UHo.|f!Fjj>x؛1CkVT8?Py-VE'ow4J1TsDy+ Ւ8y2ysw}1?[4~3M imB^8g8EɻO)R4!Wi'nB M;(tqYBv'ԙ hEÛZ HQB<&x]CqUߦK^2Xҗ $i ِ/ypьb8]ВpO倡Qа6fdV\JMmϨ.-MF^Tհ:Zpif6U%G4˖6:"u|w4cjkA1 ],F=0e^nD+9,g/ Oࢸ9--M\ hf"/]0ga}˵o5$󯉆.pH>19^mj`W"j[qvt= \v/YKK'hFܢ)  Vjo !M zڃvPByIz*WTf|O#h̕&\UlaN/N]q!zCw@07r&kY^,M0Y%kǯ9Hަ S1SݫC `襏,D "M4n-&kDK 4@ö QG6m| LPL1 棝|(Ǜn{n;.KM;`^}_AfA#є)oʦ9scX|S|EM8)!|43LO Z\Rt@oӔ2%@;8p1=jRQBASo=͋Ӑ]z3&i~W4wvAQ'KS,i@@3y@S-m{AfX" TIB46@<`TIM)4tfzʁƏE;Y,8Ѵ+4+qHt 1銩+7,[M+FG#'4_|fؔڥ-h$+HCh$r46{lm&,+4ZE3ȋԲsRG\j:8h~Si40Oo$uK,AOeLaUCR0\83;{跛 GmT?y,Ǿ8ڍ`[1 h8ܣ"۱!/L.h`cˎtL%IU444b[qvx:NLZA`17.$ CIg>LyO]kPɪܱ A I| Fh/є:s5QxnVSn6,i^ݰU+-1>54qZ&9KpUX)W>G# .x1Omx!lϖCIF+h6;4^;ea5x7ۍ:}4T46X|iF/#)UЬ0Wϖʋ+\N25͚p-ڐnxif:LYhHBh~yEv6}準<&T^?B\L/&"gU|nb@x6= s3 eE#ajnh ˺@Ӫ*;ppvMf!`.c*^ؑnK&U5&hrA54Ԁ W&T?ѽ-fz  hCBB+yAÓԻ]}ҌJmL0[3jgޘq~D.ތ҃F럿wk'%w޷6fȱk,ٯuY ox!ZARp%MWD+Za>ꤥE]+B* 6a0|F.&.ua}D*L4WW5^3}:¾ \_i}pS 81";߈y1ҎΪHjQ=XIf-#uډ%;(,E@[m_5 M2J<Ԡ!YAkր *Ӥt# *1L&jMiMnUp;Ic-}nhYӢ|:%Tu= 0vOFގi p _8tm[Lb :Ҭi`4Qil\{ݡ"+G4 ו|Dڎr󿻦ܙΊ+j~|rkjMVgـn'@eJ_U~iNR Ov>gQVh`^&*էj/vAiB:~Hr$V?ζ6!X!6ug6&'&G{qKSluE/F 2 -8x&\faโ#^o۵֯4͖!2%6(&ifWRKiUfSM0sT) )- \)79op!H@MKF4B{ܯD<8X.ьJMn+^Mv!W-Ml؃id+N1I۶kMu_i쟤-> R84dg)67)4xМe[/Cu %(F_3n0aXU "t5],+Ԝƺ$=nL~Q!Xk"Bdz̷i$e!Ѵy.RI[sf=SS <Gڐh*WiM$=Ε~?<_Q  1ˊyGw 2-x34 h-f҈M[ ]}J@UAMХgۚA7IiLWœo:M,$O]5%hOy]#2li86h\uf̗s44y|h~Le sfZ *C;^\9si)RbҔE텞Ywe'f_ ZқG‘6AaJ,0ܥ{Mpԃ1`lbTf{.̈́hp L#͇`n,q,mx)NƷv,M瓖ه4Т;[Z_Kʒf<57h8_-ͲW0ЬV9Ʊ3*_yfF ,4nqyfiU=Ͳ.Migik%XާY۸Dܕ`J~]?&ߖBsҡS0_9tBvXnx}JʩeَFea>he`J' 4-g^?L3m L`vm~=yt01h@*B*ph4OR4 oformh2 OJQJaJ<Ob< oformtextCJOJQJaJj@sj o Table Grid7:V0;;d 'z Ou };0>M  defgl-<ijkl28LMNO&'()Inop?@ $ % E F   !"#$,-./5STU^_`abcd   <r `V`ث} } ث<$$$$$$$$$Ps$$^$$*UU$$ L$$($ N .  N . $$DDY$$$$J Y$$$$ww$$2$$$$$$$$$$$$$$$$$$$$$$$$$$$$$aaaBaaa$$$$$$$$$v:$v:$v:$0=>Mt  defgl-<ijkl28LMNO&'()Inop?@ $ % E F   !"#$,-./5STU^_`abcd    6789<0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0@0 0@0@0@0@0@0@0@0@0@0@0@0@0@0 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0 @0@0 @0 @0 @0@0@0 @0 @0 @0@0@0@0@0@0@0@0@0@00@000@000@000@0000@000@0  defgijklLMNO&'()nop!ST`a<00CTb0  00@CTb0  00@CTb0  00@CTb0  00 @CTb0  00sCTb0  00s000000 00s@8>00 @0  00@0  0 0 @00 0000 0000 00%00 00%00 0 0!%00 0"0#%00 0$0%%00 0&0'%00 0(0)%00 0*0+%00 0500-0.h0-00-0 @00102h @000304h @00 @00  +++. C J\ )-   i k GI*\\\\!"#$%&'(*+,/01\ +blx+<Hg 08DJ$IU5AQ;FFFFFFFFFFG$G$FFF8@0(  B S  ?; Text1Text2Text10Text11Text3Text4Text6Text5Check1Check2Text8Text7Text9<9I5< c,h1K%R< ( L) F * I + \U , p#- ,q#. lq#/ q#0 q#1 ,r#GGSS6 6 < LLXX; ; < >*urn:schemas-microsoft-com:office:smarttags PostalCode9 *urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsplace @  (/  789< 0I  789<:::/t   5<  78<Z?@ABCDEFGHIJKLMNOPQRSTVWXYZ[\]^_`abcdefghijklmnopqrtuvwxyz|}~Root Entry F0&$Data 3B1TableUp:WordDocument7dSummaryInformation(sDocumentSummaryInformation8{CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q