Form Epa 4235 PDF Details

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QuestionAnswer
Form NameForm Epa 4235
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOIT Application_12 14 2012 ohio epa operator certification application form

Form Preview Example

4. Training

7. Oath

Operator-in-Training (OIT) Documentation Form

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)

(

 

)

(

)

 

 

 

 

 

 

 

 

(Home Phone)

(Business Phone)

(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,

 

 

or plead guilty to, a criminal charge

 

 

of falsification, fraud or terrorism?

Yes

No

Have you ever had any Ohio

 

 

operator certifications revoked or

 

 

do you have a certification under

 

 

suspension?

Yes

No

Have you had a certificate

 

 

revoked or currently suspended

 

 

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

I

 

II

 

III

I II

6. Valid Ohio Certificates You Currently Hold

Title:

Address:

Phone:

Wastewater Treatment

Wastewater Collection

I

 

II

 

III

I

 

II

 

 

 

 

 

Water Supply

Water Distribution

 

Check Correct Classes

 

 

LA

A

I

II

III

IV

 

 

I

II

 

 

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 3745-7-06, attach a copy of your transcript or degree.

Wastewater Treatment

Wastewater Collection

LWA A I

II

III IV

I

II

 

Supervisor

Signature:

Date:

EPA 4235 (Rev. 10/12)

Return this completed form to:

Ohio EPA, Certification Unit, P.O. Box 1049, Columbus, Ohio 43216-1049

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

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

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 full-time employee, record time in months. If you are a part-time, seasonal or temporary employee, record your experience time in hours.

(Attach additional sheets if necessary.)