Additional Instructions for This Form Are on the Back of the Page

Incinerator Certificate/Recertification Application

Name (as registered)
Organization
Mailing Address
Email
Phone (primary)
Date of Request
Certificate Information
Name (as you want it on the certificate)
Home Address (if different then mailing address)
Phone (alternative)
Social Security Number (for certification purposes only)*
Organization (if different from above)
Payment Information
Check Information
(for operators only) / Check #
$200.00

*Social Security Number – Please enter the full number for new certifications only. If you are requesting a recertification, we only need the last four digits of your social security number.

Additional instructions for this form are on the back of the page.

To request ADA accommodation including materials in a format for the visually impaired, call Ecology at 360-407-6900 or visit . People with impaired hearing may call Washington Relay Service at 711. People with speech disability may call TTY at 877-833-6341.

Complete this application if you have passed the incinerator operator certification exam, or if your certificate has expired. Certificates that are not renewed can be suspended or revoked.

Certificates and recertifications will be awarded to those who pass the exam, submit this application. Operators also need to submit the certification fee payment with their application. Once the certification program manager receives your application and if applicable, confirmation of payment, your certificate will be mailed to you. Certificates are valid for three years.

Operators: The certification and recertification cost is $200.00 and is valid for three years. This fee must be paid within 30 days of the date of notification (WAC 173-300-120). If you require a special invoice, contact the Cashiering Section at (360) 407-7095. Send this application and $200.00 (check payment only) to:

Department of Ecology

Cashiering Unit

PO Box 47611

Olympia, WA 98504-7611

Inspectors: If you are a government agency employee who inspects facilities for regulatory compliance, by rule, you are not required to pay for renewal if you have proof of employment. Send this application (no payment required) via email: or to the following address:

Michelle Andrews

Department of Ecology

PO Box 47600

Olympia, WA 98504-7600

If you have any questions, please contact Michelle Andrews at (360) 407-6113 or email at .

ECY 070-443February 2018