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Sample Applciation for Contractor Approval


Application for Contractor Approval Template




Contractor Application for Approval


I. Applicant Information:

Company Name:

________________________________

Email Address:

________________________________

Owner:

________________________________

Phone Number:

________________________________

Fax Number:

________________________________

Business

Address: _________________________

City: __________ State: ___ Zip: ____

Name of Qualifying Party:

________________________________

State ID for Qualifying Party:

________________________________

State of Issuance:

________________________________

II. Certification of Compliance:

I, _________________________, do hereby certify that:

(Owner/Qualifying Party)

Each person who conducts activities for the company is annually accredited in accordance with the provisions of the State; The company has access to at least one disposal site permitted to receive contaminated waste that may be generated during the term of the license; The company possesses worker protection and medical surveillance programs that are consistent with the requirements of the Occupational Safety and Health Administration; An accredited lead project supervisor shall be present at all times during the project; The company shall maintain all records as required by state law.

III. Statement of Compliance / Citation (Please check one): This disclosure shall include a signed statement that all penalties and fees assessed to the applicant shall have been paid in full.

[__] I have not been cited for violating the environment standards, regulations, or laws of any state or federal regulatory agency.

[__] I have been cited for violating the environmental standards, regulation, or laws of any state or federal regulatory agency. (Please include evidence that all penalties and fees accessed have been paid in full).

Are you now performing, or in the past five years have you performed any services that you are now applying for? [__] Yes [__] No

If yes, please specify the state and name of the company:

________________________________

________________________________

IV. Letter of Approval Fees for Contractors: $500 for Regular Processing and $750 for Emergency Processing. Applications for regular processing are reviewed in order of receipt and may take up to thirty days. Applications for emergency processing will be reviewed and processed in five days or less after receipt of the required documentation. Fees are paid the State Department of Environmental Quality. Please submit all application materials and appropriate fees to the following address:

Address: _________________________

City: __________ State: ___ Zip: ____

V. Statements of Regulation Knowledge and Acknowledgement for Public Records:

I hereby certify that this application, all accompanying documents, and information provided is true and accurate in accordance with state law, which states that any person who willfully or knowingly makes any false statement, representation, or certification in any form, application, record, label, report, plan or other document filed or required to be maintained under this Subtitle are subject to penalties with conviction of civil and criminal actions as outlined in this regulation.

I hereby acknowledge that the information I have provided on or with this form is to be kept in the public records maintained by the State Agency. I also acknowledge that the information will be available for public inspection and copying, and that I waive any claim that I have to that privacy in this information.



________________________________
Signature of Applicant





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