Application for Training Course Approval - UST Program - Form

/ Application for
Training Course Approval
Underground Storage Tanks (UST) Program
Doc Type: Certification Application

The completion and submission of this application form does not provide automatic approval. Once approved, the company must continue to update the Minnesota Pollution Control Agency (MCPA) with training dates and times to be available to post on the MPCA Operator Requirements Web page. You will be required to periodically submit information to the MPCA, including student rosters, student information, and other information as requested.

Send completed form to: / Jenalee Boese
Minnesota Pollution Control Agency
520 Lafayette Road North
St. Paul, Minnesota 55155-4194

Company Information

Name of firm or organization:
Mailing address:
City: / State: / Zip code:
Web page address:

Contact information

Contact name: / Title:
Phone: / Fax: / E-mail:

Type of Training Offered (Select all that apply.)

Online Classroom On-site

Other (please explain):

Courses to be offered (Please list contact hours* along with course name.)

Name of course / Contact hours
1)
2)
3)

*Approval is granted for contact hours only; course registration, business meetings, and lunch or dinner breaks are not considered instructional contact hours.

Previous training provided

(Include the city and state where training was provided and if this is a State approved training.)

1)
2)
3)
4)
5)

Please attach the following:

I.  A letter from the training course sponsor that clearly indicates how the course meets the requirements of Minn. R. ch. 7150.

II.  A copy of the course curriculum and materials, including but not limited to, student manuals, instructor notebooks, presentations, and handouts (see curriculum guidance).

III.  A copy of the certificate that will be issued to students who attend the course.

Certification

I certify that the information submitted is accurate and complete to the best of my knowledge; and that the requirements set forth in Minn. R. ch. 7150 are taught accurately and in their entirety.

Company contact

Print name: / Title:
Signature: / Date:

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats

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