ࡱ> '` .bjbjLULU g.?.?hDllll8T<LN6 6 6 L Z#X$$L$hQ51"@8#"5151ll6 L d33351vlR6 L 35133"3L  pt-13$z03E233 8%(3Z+ f-8%8%8%K3^8%8%8%51515151  llllll REQUEST FOR 30 DAY EXTENSION Requests for thirty (30) day extensions of individual certifications must be mailed or faxed to the department, and be received at least 14 calendar days prior to expiration. Extensions allow certified individuals to continue working until refresher training is completed and a renewal application is in process, or, the 30 days have expired. Certifications which have already expired cannot be granted an extension. Note: 30 day extensions are for state certification only and do not extend EPA accreditation. DO NOT engage in AHERA activities without current training. Name of applicant:  FORMTEXT       Certification #:  FORMTEXT       Expiration date:  FORMTEXT        FORMCHECKBOX  Asbestos:  FORMCHECKBOX  Lead: Employer:  FORMTEXT       Address:  FORMTEXT        FORMTEXT       City  FORMTEXT      , State  FORMTEXT       Zip  FORMTEXT       Has refresher training been scheduled?  FORMTEXT       If yes, when  FORMTEXT      / FORMTEXT      / FORMTEXT       Name of training provider:  FORMTEXT       Signature: Date:  FORMTEXT      / FORMTEXT      / FORMTEXT       Mail or fax to: Sandy Moody, Environmental Technician Maine DEP 17 State House Station Augusta, Maine 04333-0017 Fax: (207) 287-6220 Request for 30 day extension.dot     STATE OF MAINE Department of Environmental Protection PAUL R. LEPAGE PATRICIA W. AHO GOVERNOR ACTING Commissioner AUGUSTA17 STATE HOUSE STATIONBANGORPORTLANDPRESQUE ISLEAUGUSTA, MAINE 04333-0017106 HOGAN ROAD, SUITE 6312 CANCO ROAD1235 CENTRAL DRIVE, SKYWAY PARK(207) 287-7688 FAX: (207) 287-7826BANGOR, MAINE 04401PORTLAND, MAINE 04103PRESQUE ISLEX Z   . 0 D F H R T z |    . 0 D wjh.3Uj\h.3Ujh.3U jhHh.3UmHnHujthHh.3U hHh.3jhHh.3U h.3>*jh.3UmHnHujh.3Ujh.3U h.35h.3 h.35CJ *   V X d f ~$`^``a$gd.3gd.3gd.3h,.D F H R T j l  " $ & 0 2 < > R T V ` b d ڿڴکڞړڈjph.3Ujh.3Ujh.3Ujh.3Ujh.3U h.3>*j,h.3Ujh.3Uh.3jh.3UmHnHujh.3UjDh.3U5 "68:DFHJ^`bln *,.0DFHRTVXlnpz|abf"jh.3OJQJUmHnHuj2h.3Ujh.3UjFh.3U h.3>*jh.3UjZh.3Ujh.3Uh.3jh.3UmHnHujh.3U31Eghjkmnpqstuvwxyz{|}gdPWgd.3$a$gd.3fghiklnoqrtuvyz{|}~ɯ~ocRHhI<*B*CJph h=ih.35B*CJ^Jphh.3B*CJ^Jphh=ih.3B*CJ^Jph,h=ih.3@B*CJOJQJ\aJph2hMh.35:@B*CJOJQJ\aJph2h=ih.35:@B*CJOJQJ\aJphjh.3UmHnHuh.3hI<*hH7jhH7UhPWh.3hPWOJQJmHnHu} $If^gd| $If^gdM  $If^ gdMgd)kH  H$gd)kH $0^0gd  $0dh^0gd  $ 0!a$gd)kH $da$gdq~:;JTydydySydSESyh.3@ B*CJaJph!h=ih.3@ B*CJaJph)h=ih.3@ B*CJOJQJaJph!h=ih.3@ B*CJaJphh.3h=ih.3B*CJ^Jph h}h.3;B*CJ^Jph$hI<*h.3;B*CJ ^JaJ ph!hI<*hI<*B*CJ ^JaJ ph h}h.3;B*CJ ^Jphh}h.3B*CJ^Jphh=ih.3B*CJph$-:~qddW $If^gd| $If^gdM  $If^ gdMkd$$IfTl\ 8 H-   ` t-644 laytMT:;Um|~qddW $If^gd| $If^gdM  $If^ gdMkdp $$IfTl\ 8 H-   ` t-644 laytMT,~qddW $If^gd7 $If^gd|  $If^ gd|kd8 $$IfTl\ 8 H-   ` t-644 laytMT,,,,,,O,q,r,,,,,,,,,,,,,,r.s........ɩ}uhuXhRhu h.30Jj h.3B*Uphjh.3B*Uphh.3B*phh.3B*CJOJQJph h.3>*hH7h.3!h}h.3@ B*CJaJphh=ih.3B*CJ aJ ph!h=ih.3@ B*CJaJph)h=ih.3@ B*CJOJQJaJphU!h=ih.3@ B*CJaJphh.3@ B*CJaJph , MAINE 04679-2094RAY BLDG., HOSPITAL ST.(207) 941-4570 FAX: (207) 941-4584(207) 822-6300 FAX: (207) 822-6303(207) 764-0477 FAX: (207) 760-3143 web site: www.maine.gov/dep Date received: Date approved: Comments: AUGUSTA 17 STATE HOUSE STATION BANGOR PORTLAND PRESQUE ISLE AUGUSTA, MAINE 04333-0017 106 HOGAN ROAD 312 CANCO ROAD 1235 CENTRAL DRIVE, SKYWAY PARK (207) 624-6550FAX: (207) 624-6024 BANGOR, MAINE 04401 PORTLAND, MAINE 04103 PRESQUE ISLE, MAINE 04769-2094 RAY BLDG., HOSPITAL ST. 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