Dep 065 Form PDF Details

recent changes to the Department of Labor's Form Dep 065 have caused anxiety for many employers. The new form, which is designed to track employee leave, has been met with mixed reviews. While some employers find the new form helpful in tracking leave, others find it difficult and time-consuming to complete. In this blog post, we will discuss the changes to the Form Dep 065 and provide tips on how to complete it accurately and efficiently. We hope that this information will help ease your anxiety and make filing this form a little less daunting!

Form NameDep 065 Form
Form Length1 pages
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



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: _________________________________


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.


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.


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


I will devote ____ hours per





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

_______________________________ _______________________




License Class/No. Phone No.


License Class/No

Phone No.







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


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.



To: Applicant

Date Recorded: ____________

From: The Licensing and Pesticide Operations


Department of Environmental Protection


This request has been processed and the records updated accordingly.

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licensed operator form wastewater writing process clarified (step 1)

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

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