Dep 065 Form PDF Details

In the realm of environmental regulation and compliance, the state of New Jersey maintains a rigorous standard for overseeing wastewater facility operations. The DEP-065 form, a critical document emanating from the New Jersey Department of Environmental Protection's Licensing and Pesticide Operations, underscores this regulatory framework by facilitating the notification process for changes in the status of wastewater facilities' licensed operators. Tailored specifically to manage transitions smoothly, this form encompasses various significant details, including applicant information, employment notification, and requisite acknowledgments from the facility seeking the licensed operator's services. Its structured sections—ranging from personal contact information and licensure details to affirmations of the applicant's readiness and commitment to the role—serve to streamline the process by which operators notify the state of their engagement or departure from specific duties. The form also mandates a thorough validation by the facility itself, ensuring a bilateral acknowledgement of the operator's role. Beyond mere administrative procedure, the DEP-065 form functions as a vital link in the chain of accountability and environmental stewardship within New Jersey, requiring complete accuracy and timeliness in its submission to avoid operational disruptions and ensure compliance with state environmental standards.

QuestionAnswer
Form NameDep 065 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnj licensed wastewater, nj form wastewater, licensed operator form wastewater, nj dep employment notification

Form Preview Example

DEP-065 01/2016

State of New Jersey

Department of Environmental Protection

Licensing and Pesticide Operations

Mail Code: 401-04E, PO Box 420

Trenton, New Jersey 08625-0420

www.nj.gov/dep/exams

LICENSED OPERATOR IN CHARGE EMPLOYMENT NOTIFICATION FORM-WASTEWATER

SECTION I

Applicant Phone Numbers:

 

1. Home:

2. Business:

3. Emergency

__________________

_______________

__________________

Applicant Signature: ______________________________________

Applicant Name: ________________________________________

(please print)

Home address: __________________________________________

City: _______________________ State:______ Zip:____________

Applicants License No(s): _______________________________

License Class(es): _____________________________________

Employment Start Date: _________________________________

SECTION II

Facility Name: _________________________________________

Facility Classification: _____________________

Mailing Address: _______________________________________

City_______________________ State ________ Zip __________

County/Municipality: ____________________________________

PWS ID Number: _____________________________

This is a request to be the operator in charge at the above facility.

*This is notification that on __________ I shall no longer be the operator in charge at the above facility. If you have checked this box, do not complete Section III and IV of this form.

SECTION III

Your request to operate the above facility, as the licensed operator in charge will be considered provided this form is complete in its entirety. NO ACTION WILL BE TAKEN IF DATA AND SIGNATURES ARE MISSING.

1.

Have you been to the plant to evaluate the time required to operate the facility efficiently? Yes No

2.

I will devote ____ hours per

 

week

 

month.

3.Name(s), license classification(s), and contact number(s) of licensed individual responsible and available during your unavailability?

_______________________________ _______________________

________________________________

_____________________

Name

License Class/No. Phone No.

Name

License Class/No

Phone No.

 

 

 

SECTION IV

STATEMENT FROM REQUESTING FACILITY

 

Please be advised that the facility known as __________________________________ will be utilizing the services of the above applicant

as the licensed operator for their system with the following classification(s):___________. I acknowledge that ______________________

will be the licensed individual responsible during the unavailability of the applicant.

__________________________________________________

_____________________________________

_____________________

Signature (authorized representative of requesting facility)

Printed Name

Title

Any changes in this employment should be forwarded to this office at least two weeks prior to the job termination by completing another DEP-065 Licensed Operator In Charge Employment Notification Form.

If you have any questions, please contact the Licensing Unit (609) 292-4911.

 

FOR OFFICE USE ONLY

To: Applicant

Date Recorded: ____________

From: The Licensing and Pesticide Operations

 

Department of Environmental Protection

 

This request has been processed and the records updated accordingly.

How to Edit Dep 065 Form Online for Free

nj dep dep licensed operator can be completed easily. Just open FormsPal PDF tool to finish the job fast. FormsPal team is dedicated to providing you with the best possible experience with our tool by consistently presenting new features and upgrades. With all of these updates, using our tool becomes easier than ever before! Should you be seeking to get started, this is what it takes:

Step 1: Open the PDF in our tool by clicking on the "Get Form Button" at the top of this webpage.

Step 2: When you access the tool, you'll see the document made ready to be filled out. Apart from filling out different fields, it's also possible to perform other sorts of things with the Document, particularly writing custom textual content, editing the initial textual content, adding graphics, signing the form, and a lot more.

This form requires specific details; to ensure consistency, remember to take heed of the tips below:

1. First, while completing the nj dep dep licensed operator, begin with the section that contains the subsequent fields:

licensed operator form wastewater writing process clarified (step 1)

2. Now that this part is completed, it's time to add the needed particulars in SECTION III Your request to, week month, SECTION IV STATEMENT FROM, FOR OFFICE USE ONLY, and To Applicant Date Recorded From so you're able to progress further.

FOR OFFICE USE ONLY, SECTION IV STATEMENT FROM, and week month of licensed operator form wastewater

It's easy to make errors when completing the FOR OFFICE USE ONLY, so make sure that you look again before you send it in.

Step 3: Before getting to the next stage, double-check that all blanks are filled in the right way. When you believe it's all fine, press “Done." Join us today and easily obtain nj dep dep licensed operator, set for downloading. Every single change you make is conveniently saved , making it possible to customize the pdf later as required. FormsPal is focused on the privacy of our users; we ensure that all personal information put into our editor is kept protected.

Dep 065 Form isn’t the one you’re looking for?

Related Documents