APPLICATION FOR ACCREDITATION
|Department of Labor and Industries | |APPLICATION FOR ACCREDITATION |
|Division of Occupational Safety & Health |[pic] |Cranes/Derricks and other |
|PO Box 44650 | |Material Handling Devices |
|Olympia, WA 98504-4650 | | |
|Office: (360) 902-4943 | | |
|Email: LNICranes@Lni. Fax: (360) 902-5438 | | |
|In what industry do you want to inspect cranes? | | Construction WAC 296-155 |
| |Maritime WAC 296-56 and 296-304 | |
| |(Must show Maritime experience) | |
|What types of Cranes and/or Material Handling Devices do you want to inspect? (check) |
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|You must show experience/training for each category you are applying for. |
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|Container Cranes (Maritime only) |
|Mobile Cranes |
|Articulating Cranes |
|Portal and Pedestal Cranes (Maritime only) |
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|Overhead/Bridge, Jib & Gantry Cranes |
|Tower Cranes & Self Erectors |
|Conveyors, Spouts and Suckers (Maritime only) |
|Cargo Handling Gear (i.e. Spreaders, Special Stevedoring Gear, etc.) (Maritime only) |
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|3. Name of Applicant |4. Business Name |
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|5. Business Address |City |State Zip + 4 |6. Business Phone No. |
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|7. Email Address: |
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|8. References – list four (4) who can furnish information regarding cranes & material handling devices inspected by applicant. |
|Name |Title |Phone No. |
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|Address |City |State |Zip + 4 |
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|Name |Title |Phone No. |
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|Address |City |State |Zip + 4 |
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|Name |Title |Phone No. |
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|Address |City |State |Zip + 4 |
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|Name |Title |Phone No. |
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|Address |City |State |Zip + 4 |
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|9. Applicable types of crane inspections performed in the past. Attach list noting amount and extent of such inspections within the past five (5) years, |
|for who inspection was accomplished, to whose requirements, and equipment involved; also attach completed worksheets, or equivalent evidence. (Note: All |
|applicants must show at least five (5) years crane related experience, of which two years must be actual crane inspection activities.) |
|10. Description of testing instruments, make and model of non-destructive test equipment, etc. Attach test reports less than six (6) months old giving |
|accuracy date for physical testing equipment. (if none, so state) |
|11. Attach a resume outlining education/training, experience, and any other qualifications you feel are relevant that shows testing, examining and |
|inspecting cranes/derricks, and other material handling devices. |
|12. If currently certified to operate a crane, please provide a copy of certification, otherwise state “None”. |
|The undersigned certifies that all statements made in this application are true to the best of his/her belief and grants permission for the Washington |
|State Department of Labor & Industries to contact any persons relative to statements made herein. If granted accreditation, it is understood that the |
|undersigned will comply with all applicable regulations of the Occupational Safety & Health Administration, RCW, and WAC. |
|Date |Title |Signature of applicant |Daytime phone # |
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F416-063-000 application for universal accreditation 7-09
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