The EPA 4235 form, a pivotal document for individuals pursuing operator certification in the water and wastewater management sectors, encapsulates a multitude of key components which encompass biographical information, educational background, and professional experience, explicitly tailored towards individuals aiming to qualify for Operator-in-Training (OIT) positions. A unique aspect of this form is its provision for applicants to substitute certain training courses for experience credits at specified certification levels, thereby opening avenues for aspirants to meet qualification criteria via alternative educational achievements. Additionally, it integrates a thorough vetting process, including inquiries into the applicant's criminal history and prior certifications, if any, thus ensuring the credibility and reliability of candidates pursuing certifications. An oath of honesty underscores the gravity and integrity of the information provided, binding the applicant to a commitment of truthfulness. Supplementing the individual's details are the requisites of supervisor verification and detailed descriptions of tasks performed in current and prior roles, which cumulatively contribute to a comprehensive dossier for the certification authority's assessment. A notable obligation set forth by the form is the explicit enumeration of duties related to water or wastewater management, further emphasizing the importance of relevant professional exposure for qualification. Hence, the EPA 4235 form serves as a critical pathway for aspiring water and wastewater operators to document their qualifications, experiences, and commitments towards achieving certification in Ohio.
| Question | Answer |
|---|---|
| Form Name | Form Epa 4235 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | OIT Application_12 14 2012 ohio epa operator certification application form |
4. Training |
7. Oath |
1. Biographical Information
Core Person ID or your SS#
(Core Person ID is the middle seven digits of your certification number)
Print Name:
(Last) (First) (MI)
Mailing Address:
(Number) (Street)
(City) (State) (Zip)
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(Home Phone) |
(Business Phone) |
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(County)E-Mail
2. Which exam did you take?
A list of training courses which can be substituted for experience credit at the class II and II level can be found on the Operator Certification web site:
http://epa.ohio.gov/portals/28/documents/opcert/ courses_substituted_for_experience.pdf
Training will NOT be substituted for months of experience unless the course completion certificate is attached.
5. Background
Have you ever been convicted of, |
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or plead guilty to, a criminal charge |
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of falsification, fraud or terrorism? |
Yes |
No |
Have you ever had any Ohio |
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operator certifications revoked or |
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do you have a certification under |
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suspension? |
Yes |
No |
Have you had a certificate |
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revoked or currently suspended |
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in any other state? |
Yes |
No |
THIS APPLICATION WILL NOT BE ACCEPTED IF OATH IS OMITTED
I, the undersigned, do solemnly affirm that I am the applicant; that all statements made and information contained in this application and attachments are full and correct to the best of my knowledge and belief; and that I understand any omissions or misrepresentations may result in ineligibility for the examination applied for or revocation of any certificate granted. I also consent to a thorough investigation of my employment record and other experience in related activities for the purpose of verification of my qualifications for the certificate for which I have applied, and I hereby authorize my present and previous employers to provide information concerning the employment record listed.
Signature of Applicant:
8. Supervisor Information (print) |
Current Supervisor: |
Certification No.: |
Water Supply
Water Distribution
Check Correct Exam
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II |
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III |
I II
6. Valid Ohio Certificates You Currently Hold
Title: |
Address: |
Phone: |
Wastewater Treatment
Wastewater Collection
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II |
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III |
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II |
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Water Supply
Water Distribution
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Check Correct Classes |
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LA |
A |
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II |
III |
IV |
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II |
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I certify that the statements on this application |
are true to the best of my knowledge and belief |
based on my supervision of the applicant. |
Date of Exam
3.Education
If you have received college credit meeting the requirements of OAC Rule
Wastewater Treatment
Wastewater Collection
LWA A I |
II |
III IV |
I |
II |
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Supervisor |
Signature: |
Date: |
EPA 4235 (Rev. 10/12)
Return this completed form to:
Ohio EPA, Certification Unit, P.O. Box 1049, Columbus, Ohio
Basic Duties and Responsibilities |
Name: |
•Describe in detail ONLY the work which applies to either water or wastewater experience. Actual operating wastewater experience includes treatment and collection. Actual operating water experience includes treatment and distribution as a public water system.
•Please list changes in employment (e.g., job title, % of time, duties, etc.) as separate employment events to ensure a more accurate evaluation of your qualifications.
•Failure to thoroughly describe water or wastewater duties may be reason for disapproval.
Current Employment Dates
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To |
Month/Day/Year |
Month/Day/Year |
Experience Time*
% Time on Wastewater Duties
% Time on Water Duties
Your Title
Employer Name
Employer Address
Public Water System ID# (if applicable)
Duties
Prior Employment Dates
From |
To |
Month/Day/Year |
Month/Day/Year |
Experience Time*
% Time on Wastewater Duties
% Time on Water Duties
Your Title
Employer Name
Employer Address
Public Water System ID# (if applicable)
Duties
*If you are a
(Attach additional sheets if necessary.)