Adem Form 12 PDF Details

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QuestionAnswer
Form NameAdem Form 12
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesForm12 adem landfill operator certification form

Form Preview Example

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

How to Edit Adem Form 12 Online for Free

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Step 1: Access the PDF in our editor by clicking on the "Get Form Button" above on this webpage.

Step 2: This editor helps you change PDF forms in various ways. Change it by writing any text, correct what's already in the file, and put in a signature - all at your convenience!

It will be easy to fill out the form using this helpful tutorial! Here's what you want to do:

1. It's vital to fill out the Adem Form 12 accurately, thus be mindful while filling in the sections containing these fields:

Adem Form 12 completion process described (part 1)

2. Right after finishing the last part, go on to the next stage and enter the necessary details in all these blank fields - APPLICANT INFORMATION Mr Name, School and Year of Graduation If, STATE , and Expiration Date .

Filling out section 2 in Adem Form 12

Always be really attentive while filling out APPLICANT INFORMATION Mr Name and STATE , because this is the part in which many people make some mistakes.

3. This subsequent section is usually fairly straightforward, month and year, month and year, Attach additional sheet if needed, EXPERIENCE If your experience, month and year, and month and year - these blanks will have to be filled out here.

Writing segment 3 in Adem Form 12

4. To move onward, this part requires filling out several fields. Examples include EXPERIENCE If your experience, I the undersigned do hereby affirm, Attach additional sheet if needed, NOTICE, Before mailing please be sure that, and Operator Certification Section, which you'll find essential to carrying on with this form.

Part number 4 in completing Adem Form 12

Step 3: Check that your details are accurate and simply click "Done" to progress further. Go for a 7-day free trial subscription with us and gain instant access to Adem Form 12 - which you are able to then use as you would like in your personal cabinet. We don't share or sell the details you use when completing documents at our site.