Application for Certification Renewal
DEP REN Revised 8-2009
|Mail to: |Commonwealth of Kentucky |For Official Use Only. |
| |Department for Environmental Protection |Do not write in this space. |
|Division of Compliance Assistance | | |
|Certification and Licensing Branch |Application for Certification Renewal | |
|Operator Certification Program | | |
|300 Fair Oaks Lane |Drinking Water Treatment, Drinking Water Distribution, | |
|Frankfort, KY 40601 |Bottled Water, Wastewater Treatment and Collection System | |
| | | |
| |Telephone: 800-926-8111 | |
| |dca.certification | |
|If you currently hold an Operator-In-Training certificate, you must provide a new Education and Experience Documentation Form (EED) verifying your one year of |
|experience. The EED Form must be attached to this Application for Certification Renewal. |
|APPLICANT INFORMATION |
|Name (First) (Middle Initial) (Last) |Agency Interest Number (As shown on wallet card) |
| | |
|Certification Type (As shown on wallet card) |Certification Number (As shown on wallet card) |
| | |
|Address (Number and Street) |City |State |Zip Code |
| | | | |
|E-Mail Address |Home Phone Number |Business Phone Number |
| |( ) |( ) |
| |
|FACILITY INFORMATION |
|List all facilities where you currently work as an operator. Attach additional sheets as necessary. |
|Facility Name |County |KPDES, PWSID or Agency |Start Date |Design Capacity, Daily |Phone Number |
| | |Interest Number | |Flow of Facility or | |
| | | | |Population Served | |
| | | | | | |
| | | | | | |
| | | | | | |
| |
|CONTINUING EDUCATION List all “Board Approved” training hours that are being used for this renewal. All hours must be earned prior to applying for certification |
|renewal. If more space is needed, attach additional sheets to this form. |
|Course Code |Training Course Title |Sponsor or Presenter |Date |Hours Earned |
|(Available from DCA or| | | | |
|the training vendor) | | | | |
| | | | |Drinking |Wastewater |
| | | | |Water | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Renewal applications must be submitted with a check or money order made payable to the Kentucky State Treasurer. Applications submitted without payment will not be processed. Renewal fees are non-fundable and are as follows:
• Certification renewal fee if submitted prior to certification’s expiration date ………$100.00
• Certification renewal fee if submitted electronically prior to certification’s expiration date $50.00
• Certification renewal fee if submitted after the certification’s expiration date (late fee plus renewal fee) $350.00
• Certification renewal fee if submitted electronically after the certification’s expiration date (late fee plus renewal fee) $300.00
| |
|Amount Paid: |
| |
|Check Number: |
|Do not write in this space. |
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