Fillable Printable Form 4728

Form 4728

FOR OFFICE USE

Classification

Status

Remarks

APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR

CERTIFICATION EXAMINATION

State Form 47289 (R7 / 2-15)

Approved by State Board of Accounts, 2014

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Pursuant to 327 IAC 5-22

NOTE: A $30.00 FEE MUST BE SUBMITTED FOR EACH CERTIFICATION EXAMINATION APPLICATION.

FAILURE TO FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN THE APPLICATION

BEING DISAPPROVED. APPLICATIONS ARE DUE NO LATER THAN 45 DAYS

PRIOR TO THE DATE OF

THE EXAMINATION IF YOU INTEND TO TAKE THE EXAM AT IDEM. THERE IS NO DUE DATE IF YOU

PLAN TO TAKE THE EXAM AT IVY TECH. (APPLICATION FEE IS NONREFUNDABLE.)

II. EDUCATION AND TRAINING-Must be com

leted for certification a

licants, o

tional for a

rentice a

licants

List below all high schools and post high schools attended.

Name/Location of School

From (month/year) To (month/year)

Diploma (GED) or Type of

Degree and Date of Graduation

High School Graduate?

Yes No

College Graduate?

Yes No

Other:

If you are applying for Class IV / Class D certification, original transcripts must be enclosed. For the consideration of using college education

to substitute for work experience, original college transcripts must be enclosed.

If you would like to have your original transcripts returned, please check the box and enclose a self-addressed, stamped envelope.

Specialized Training or Classes Relevant to Certification

Title of Specialized Training or Class

Company/School Attended

Dates Attended

(month/day/year)

Credits or Contact Hours

earned:

Copies of credit report forms or proof of attendance must be enclosed.

"Contact Hour" means a fifty (50) to sixty (60) minute instructional session, approved by the Commissioner and involving a qualified instructor or

lecturer. Ten (10) contact hours equals one (1) continuing education unit (CEU).

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1. This is an application for: (check one)

Wastewater Apprentice Certified Operator

2. Classification requested: (check one) Industrial: A-SO A B C D

Municipal:

I-SP I II III IV

3. If you are applying for Certified Operator, would you accept a lower operator classification if you do not currently meet the education and experience

requirements for your first choice?

YES NO

4. Where would you like to take the exam?

At IDEM in Indianapolis when it is next offered (annually in October). This is a paper exam only.

At one of the participating IVY Tech locations (any standard business day).

Note: Ivy Tech charges an additional $30 fee for administering the test. This is a computerized exam only.

I. GENERAL INFORMATION FOR

PPLICANTS

(

please t

pe or print le

ibl

A. Name of applicant (last, first, middle )

Mr. Miss Mrs. Ms. Dr.

B. Mailing address (number and street ):

City: State: ZIP code: County:

Office telephone number:

( )

Home telephone number:

( )

Fax number:

( )

E-mail address:

C. Date of birth: (month/day/year) D. Have you ever applied for wastewater certification in Indiana before?

Yes No

E. Are you presently a certified operator in Indiana?

Yes No

Certification number:

Date of expiration:(month/da

ear)

Reset Form

III. OPERATIONAL EXPERIENCE HISTORY-Must be completed for certification applicants, optional for apprentice applicants.

List your current assignment first. Show all acceptable experience in wastewater treatment plants. “Acceptable experience” means

employment in the actual hands-on operation, maintenance, management, or supervision of a wastewater treatment plant. Acceptable

experience shall be obtained under the supervision of a certified operator or by otherwise demonstrating that your experience meets the

requirements.

Date

Position Information

From: To:

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

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IV. RESPONSIBLE CHARGE

EXPERIENCE

(Must be completed by Class III, IV, C, and D certification applicants; optional for other classes)

List specific duties for positions of responsible charge. “Responsible charge” means the certified operator who makes process control or system

integrity decisions about the overall daily operation, maintenance, management, or supervision of a wastewater treatment plant necessary to meet

the performance requirement and limits of the assigned permit and any applicable local ordinance or other regulatory requirements. In Class III,

IV, C, or D plants, the individual supervising and responsible for a major section of the plant or an operating shift may be credited with responsible

charge experience. Additional sheets may be attached, as necessary.

Date

Position Information

From: To:

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

mm/yy mm/yy

Title of position Name of facility Class of facility Location (City & State) of Facility

Hours Per Week

in Wastewater

Treatment

Cert.Op.in Responsible Charge/Facility Type of Treatment/Average Flow NPDES Permit Number

Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the

supervision of a certified operator)

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. SIGNATURE OF

PPLICANT (Required)

I, the undersigned, certify that I am the above applicant; that all statements made and information regarding education, training, acceptable

experience and responsible charge experience are true and correct to the best of my knowledge and belief; that I understand that any omissions

or misrepresentations may result in ineligibility for the examination applied for, revocation of any certification granted or voiding a decision made

regarding my application. I also consent to verification of my qualifications for the certificate for which I have applied.

Signature of Applicant

Date (month/day/ year)

VI. SIGNATURE OF APPLICANT'S SUPERVISOR (Required for certification applicants, optional for apprentice)

I, the undersigned, hereby certify the information contained in Sections II, III, and IV of this application is true and correct to the best of my

knowledge.

I have supervised this individual for years.

Signature of Supervisor

Date (month/day/year)

Printed Name of Supervisor Title Wastewater certificate number if applicable

Name of Organization

Address (number and street, City, State, ZIP code)

Telephone number:

( )

Fax Number:

( )

The completed application, along with all required fees and attachments should be mailed to:

Wastewater Certification

Indiana Department of Environmental Management

Office of Water Quality – MC 65-42

100 N. Senate Ave., Room 1255

Indianapolis, IN 46204-2251

Please make all checks payable to the Indiana Department of Environmental Management.

DO NOT SEND CASH.

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