State of Alabama
Solid Waste Landfill Operator
Reciprocal Certification Application
ADEM Form 12
ADEM USE ONLY Approved ____Rejected_____
Reviewed By ________________
Applicant # _________________
Please read instructions before completing this application. Type or Print in black ink.
1.APPLICANT INFORMATION: Mr. ( )
Name: Ms. ()
Mrs. () ______________________________________________________________________________
(First) |
(Middle) |
(Last) |
(Jr., Sr., III, etc.) |
Address: ____________________________________________________________________________________
(Number and Street)(Home Telephone)
____________________________________________________________________________________________
(City)(State)(Zip)(Work Telephone)
*Social Security Number: _______________________E-mail address ____________________________________
*Social Security Numbers are used only for the purpose of recordkeeping in accordance with Sec. 7(a)(2)(a) of P.L. 93-579*
2.EMPLOYED BY:
Landfill Name: |
___________________ |
Permit # |
__________________ |
Not Currently Employed by a Landfill: ________ |
|
|
3. HIGH SCHOOL DIPLOMA: |
|
School and Year of Graduation: |
_____________________________________________________ |
If GED, List Date Received : |
______________________________________________________ |
4.CURRENT CERTIFICATION HELD:
STATE: ___________________________________ |
Expiration Date ____________________ |
ADEM Form 12 01/10
5.EXPERIENCE: (If your experience record is from more than two facilities please copy this portion of the application and submit additional pages as needed)
Landfill Name: ___________________________________________________________ |
Facility /Permit #: ________________ |
Address: _________________________________________________________________ |
City/State: ______________________ |
Type (MSW/IND/C&D): ________ Dates of Employment: From :_____________________ To: __________________________
|
(month and year) |
(month and year) |
Total Months: ________ Full Time |
Part Time |
|
Number of Hours Per Week: ________
Duties and Responsibilities:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Attach additional sheet if needed.)
Landfill Name: ___________________________________________________________ |
Facility /Permit #: ________________ |
Address: _________________________________________________________________ |
City/State: ______________________ |
Type (MSW/IND/C&D): ________ Dates of Employment: From :_____________________ |
To: __________________________ |
|
(month and year) |
(month and year) |
Total Months: ________ Full Time |
Part Time |
|
Number of Hours Per Week: ________
Duties and Responsibilities:___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Attach additional sheet if needed.)
6.APPLICATION VERIFICATION:
I, the undersigned, do hereby affirm and swear, under oath, that I am the said applicant; that all statements made and infor- mation contained in this application are true and correct to the best of my knowledge and belief. I understand that falsification of statements or supporting data may result in denial of this application or suspension/revocation of any certificate I may hold. Further, I understand that it is my responsibility to provide documentation upon request of any claims on this form and provide supplemental material to reflect any material change in circumstances which may affect my eligibility for certification.
Signature of Applicant: |
___________________________________________________________ |
Date signed: |
___________________________________________________________ |
**NOTICE**
Before mailing, please be sure that you have completed the application in its entirety. Please see ADEM Administrrative Code R. 335-1-6 Schedule G for applicable fees (Checks or money orders only). Faxed applications are not accepted. Information recorded
on this form will be verified by contacting the certification authorities in the state where current certificate is held. For more information reference ADEM Administrative Code R. 335-13-12. Mail application with appropriate fee to:
Operator Certification Section
Alabama Department of Environmental Management
Post Office Box 301463
Montgomery, Alabama 36130-1463
Visit our website at www.adem.state.al.us
ADEM Form 12 01/10
